SHIPLEY LIVING
For profit - Corporation
82 Beds
Independent
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
38/100
#26 of 43 in DE
Photo by Shipley Living
Photo by Shipley Living
Photo by Shipley Living
1 / 5 photos
Last Inspection: July 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Shipley Living has received a Trust Grade of F, indicating significant concerns about the quality of care provided at this facility. It ranks #26 out of 43 nursing homes in Delaware, placing it in the bottom half of facilities in the state, and #15 out of 25 in New Castle County, meaning there are only a few better options nearby. While the facility shows an improving trend, having reduced issues from 34 in 2024 to just 1 in 2025, it still reported a concerning number of incidents, including a critical failure in discharge planning that placed a resident at immediate risk, as well as a serious incident where a resident suffered injuries due to inadequate supervision during care. Staffing is rated at 4 out of 5 stars, which is a strength, but the facility has an average turnover rate of 51%, and it has incurred $32,394 in fines, reflecting potential compliance problems. Although RN coverage is average, the facility's health inspection rating is below average at 2 out of 5 stars, highlighting the need for improvement in maintaining safety and care standards.
- Trust Score
- F
- In Delaware
- #26/43
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 51% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $32,394 in fines. Lower than most Delaware facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 57 minutes of Registered Nurse (RN) attention daily — more than average for Delaware. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 60 deficiencies on record. Higher than average. Multiple issues found across inspections.
38/100
Bottom 40%
Review needed
34 → 1 violations
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 34 issues
2025: 1 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
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Delaware average (3.3)
Meets federal standards, typical of most facilities
Staff Turnover: 51%
Near Delaware avg (46%)
Higher turnover may affect care consistency
Federal Fines: $32,394
Below median ($33,413)
Moderate penalties - review what triggered them
The Ugly 60 deficiencies on record
1 life-threatening 1 actual harm
Jun 2025
1 deficiency
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 F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that for one (R33) out of seven residents reviewed for vaccines, the fac...
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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 (R33) out of seven residents reviewed for vaccines, the facility failed to ensure that R33 was free from a significant medication error, R33 was given two (2) sets of the PNA, influenza and COVID vaccines twelve hours apart.Findings include:
Centers for Disease Control (CDC) Vaccines & Immunizations - Timing and Spacing of Immunobiologics .General Prinicples for vaccine scheduling .Vaccination providers should adhere to recommended vaccination schedules .certain vaccines produce increased rates of local orsystemic reactions in certain recipients when administrered more frequesntly than recommended Extra Doses of vaccine antigens - .However, the risk for an adverse event might increase when extra doses are administered at an earlier time than the recommended interval for certain vaccines . Updated July 24, 2024
CDC's Recommended Adult Immunization Schedule by Age Group - For adults greater than or equal to sixty-five (65) years- COVID-19 Vaccine - 2 or more doses of 2024-2025 vaccine . Influenza Vaccine - 1 dose annually .Pneumococcal Vaccine - No prior pneumococcal vaccines, recommend PCV20 (Pneumococcal conjugate PCV20 vaccine). Revised 5/28/25
Facility's Administering Medications Policy - Policy Interpretation and Implementation . 22. The individual administering the medication initials the resident's MAR (medication administration record) on the appropriate line after giving each medication and before administering the next ones. Revised April 2019
Review of R33's clinical record revealed:
3/23/23- R33, who was seventy-three (73) years old, was admitted to the facility with diagnoses including but not limited to multiple sclerosis and dementia.
12/30/24 - C1 (consulting physician) ordered in R33's EMR, Resident may have flu vaccine when available. C1 also ordered, Resident may have pneumovax every five (5) years.
2/5/25 9:30 AM - E11 (RN/Infection Preventionist) documented in R33's Immunization tab in R33's EMR administering pneumococcal conjugate PCV20 vaccine, influenza, high-dose, trivalent, PF (135) vaccine and COVID -19 Moderna Booster (208) to R33 intramuscularly in her left deltoid.
2/5/25 9:10 PM - E10 (LPN) documented in R33's February 2025 MAR administering pneumococcal 20-[NAME] conjugate vaccine and Fluzone high-dose intramuscular suspension vaccine intramuscularly to R33.
2/5/25 9:24 PM - E10 (LPN) documented in R33's February 2025 MAR administering Spikevax Intramuscular suspension (COVID-19 (SARS-CoV-2) mRNA virus vaccine intramuscularly to R33.
2/5/25 10:11 PM - E10 documented in R33's progress notes, Resident has one-time orders for Fluzone vaccines (sic), COVID -19 vaccine, and Pneumococcal vaccine. Vaccines were administered by nurse at 2110 (9:10 PM) today after POA (power of attorney) consent verified. Flu & COVID administered on the left thigh, and pneumococcal administered on the right thigh. Nurse noted when about to document the vaccines administrations on the Immunization Tab that all the vaccines were administered this morning @ (at) 9:30 AM. Resident was immediately assessed and NP (Nurse Practitioner) [name] called at 2120 (9:20 PM).
R33, who was seventy-five (75) years old, was administered two doses of three vaccines within a twelve-hour period, when the order was for one dose of each of three vaccines.
6/4/25 10:30 AM - A review of the DELVAX website revealed R33 had no documented previous immunizations for influenza or pneumococcal infections. R33 was documented on DELVAX to have received the COVID 19 vaccine on 10/28/22.
6/5/25 11:30 AM - A review of the MAR (Medication Administration Record) for February 2025 revealed that E11 failed to document the administration of these three vaccines in R33's MAR as per the facility policy.
The failure to document the administration of the vaccines resulted in R33, who was bedbound and medically frail, receiving two doses of the same sets of vaccinations within a twelve hour period, which was not inaccordance with the CDC recommendations for these vaccines' schedules. Per the CDC Adult Vaccination Schedule guidelines, the influenza vaccine was recommended for one dose annually. The COVID-19 vaccine recommendation for persons, who were previously COVID-19 vaccinated before the 2024-2025 vaccine, included two doses of the vaccine with a minimum interval of two (2) months between the vaccinations. The CDC recommendations for the pneumococcal vaccine for persons who were not previously vaccinated for pneumococcal included one dose of PCV20. R33 did exhibit an adverse reaction with a fever of 101F and was sent to the hospital for an evaluation.
6/6/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E8 (regional nurse) and E9 (regional reimbursement) (via phone) at the exit conference.
Jul 2024
24 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews, it was determined that for one (R172) out of two residents reviewed for accidents, the f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews, it was determined that for one (R172) out of two residents reviewed for accidents, the facility failed to ensure adequate supervision was provided to prevent accidents. This failure caused R172 to roll out of the bed while one staff member was providing care. R172 sustained harm, an injury to the back of the head and fractures to her left leg. Findings include:
Review of R172's clinical records revealed:
11/14/21 - R172 was admitted to the facility with diagnoses including breast cancer, dementia, heart failure, depression.
11/21/21 - An order for a low air loss mattress (for wound pressure relief).
12/13/21 12:26 PM - A nursing progress note documented, Resident with a new stage 3 (three) wound to the sacrum .
12/20/22 3:27 PM - A nursing progress note documented, .Continued to be followed by wound care to due to stage 4 (four) to sacrum .low air loss mattress in place.
2/26/23 2:30 AM - A review of the facility incident report revealed that she fell from the bed to the floor and sustained a left leg fracture. This fall was reviewed by the facility's interdisciplinary team, and a care plan to provide a safe environment, and fall mats to both sides of the bed were added.
1/24/24 - R172's quarterly MDS assessment documented that the resident was completely dependent on staff for all activities of daily living including turning, repositioning, showers, and transfers. R172's BIMS assessment score was 6, which indicated severe cognitive impairment.
3/15/24 2:00 PM - A facility incident report submitted to the State Agency documented that R172 fell out of the bed while receiving care from an aide. R172 sustained a head injury and was sent to the hospital for evaluation. R172's hospital records documented, .Left lower leg . nondisplaced (broken bone that did not move out of alignment) fracture impaction fractures of the (left) proximal tibia (upper part of the shin bone) and fibula (lower leg bone) and a head injury.
3/16/24 - A facility document titled, Educational Opportunity Notice, and dated, 2017, documented, [E17] will be conscious of resident positioning when providing care to minimize risk of fall or injury. Verbal education provided and discuss (sic) resident handling. [E17] provided demonstration of what she would do differently, and verbalized understanding of education provided.
7/1/24 9:20 AM - A review of R172's [NAME] (electronic document for the aides to inform the staff of the residents' care needs) lacked information of how many staff members were needed to assist with turning, repositioning in bed. R172's care plan also lacked evidence of how many staff members were needed for turning and repositioning.
7/1/24 1:15 PM - During an interview, E5 (Unit Manager) stated, Physical Therapy determines how many staff members are needed for transfers, and turning and repositioning. This information is then communicated to nursing, and the order then obtained from the doctor, the [NAME] and the care plan are updated.
7/1/24 2:17 PM - During an interview, E6 (Physical Therapy Director) stated, The residents are seen on admission and evaluated for bed mobility and transfer status. This information is given to nursing for the resident's records. E6 failed to give the surveyor any documents of R172's evaluation and recommendations for bed mobility upon request.
7/1/24 2:30 PM - During an interview, E14 and E19 (CNAs), stated that they look at the [NAME] for information on residents' care including bed mobility and transfers.
7/2/24 10:30 AM - During an interview, E17 (CNA) stated, I was cleaning up the lower part of the resident's body and the top half started to roll off the bed. I tried to grab her feet but I was not able to prevent her from falling. The surveyor asked E17 if she knew how many persons were needed for R172's bed mobility, E17 stated, I usually look at the [NAME] or ask other aides about the residents' care including bed mobility and transfer status but this resident did not have any information about her bed mobility or transfers on the [NAME], so I looked to see what the other aides documented and that's what I did. The surveyor then asked E17 if R172 was able to participate in bed mobility, E17 stated, Sometimes she would reach for something, but she was not able to help with turning or anything.
7/2/24 11:30 AM - During a telephone interview F3 (R172's daughter) stated, The only thing my mother was able to do was feed herself, and that was only when the spoon was put in her hand. She was not able to move or do anything else.
The facility failed to evaluate how many staff members were needed for R172's bed mobility including turning and repositioning, and that the information was documented on the [NAME] for staff to care for her safely.
Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON) E3 (ADON), E4 (Clinical Specialist), E32 (Corporate PT) and State of DE Ombudsman (via telephone).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on record review and interviews, it was determined that for three (R18, R34 and R270) out of the survey sample of seventeen residents reviewed for resident rights, the facility failed to ensure ...
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Based on record review and interviews, it was determined that for three (R18, R34 and R270) out of the survey sample of seventeen residents reviewed for resident rights, the facility failed to ensure that the residents had the right to a dignified existence.
Findings include:
1. Review of R270's clinical record revealed:
6/19/24 - R270 was admitted to the facility with multiple diagnoses, including obstructive uropathy, and R270 had a foley catheter in place at admission.
6/25/24 - A review of R270's electronic medical record (EMR) revealed the presence of an admission care plan with interventions to care for R270's catheter, which included to place the catheter bag away from the entrance room door.
The following observations were made on 6/24/24:
10:29 AM - An uncovered urinary catheter bag hanging on the right had side of the bed, visible from the entrance room door.
12:30 PM - An uncovered urinary catheter bag hanging on the right side of the bed, visible from the entrance door.
The following observations were made on 6/25/24:
10:30 AM -R270 was sitting in his wheelchair with the ¾ urine filled catheter bag hanging on the wheelchair, and which was visible from the doorway.
11:41 AM - R270 was observed sitting in his wheelchair in the doorway of his room, with an uncovered catheter bag hanging on the back of his wheelchair. Additionally, the CNA wheeled R270 to the shower room with the uncovered catheter bag dragging on the floor.
6/26/24 10:45 AM - The above 11:41 AM observations were confirmed with E3 (ADON) and E4 (Clinical Specialist).
Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON), E3 (ADON), E4 (Clinical Specialist), and State of DE Ombudsmen (via telephone).
2. Review of R34's medical records revealed:
5/4/24 - R34 was admitted to the facility with diagnoses including neurogenic bladder.
5/10/24 - R34's clinical records documented, Ensure that tubing and dignity bag are off the floor.
5/13/24 - R34's care plan included, Privacy bag at all times.
6/24/24 10:30 AM - R34 was observed lying in the bed, an uncovered, an undated urinary collection bag with yellow urine was observed on the floor on the left side of the bed.
6/24/24 1:30 PM - R34 was observed lying in the bed, the uncovered, an undated urinary collection bag with yellow urine continued to be on the floor on the left side of the bed.
6/25/24 10:30 AM - R34 was observed lying in the bed, an uncovered, an undated urinary collection bag with yellow urine was observed on the right side of the bed on the floor.
6/25/24 2:30 PM - R34 was observed lying in the bed, an uncovered, the undated urinary bag with yellow urine continued to be observed on the right side of the bed on the floor.
3. Review of R47's clinical records revealed:
1/6/22 - R47 was admitted to the facility with diagnoses including neurogenic bladder.
5/10/23 - R47's clinical records documented, Check tubing for kinks, and privacy bag at all times, secure catheter to reduce friction.
6/24/24 10:30 AM - R47 was observed lying in bed, an undated, uncovered urinary collection bag with yellow urine was observed touching the floor on the left side of the bed.
6/24/24 2:30 PM - R 47 was observed lying in bed, an undated, uncovered urinary collection bag with yellow urine continued to be touching the floor on the left side of the bed.
6/25/25 10:00 AM - R47 was observed lying in bed, an uncovered, undated urinary collection bag with yellow urine hanging on the right side of the bed and visible from the doorway.
6/25/24 2:30 PM - R47 was observed lying in bed, an uncovered, undated urinary collection bag with yellow urine in a wash basin was on the left side of the bed on the floor.
6/25/24 3:00 PM - Findings were confirmed with E3 (ADON) and E4 (Clinical Specialist).
Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON) E3 (ADON), E4 (Clinical Specialist), E32 (Corporate PT) and State of DE Ombudsman (via telephone).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0553
(Tag F0553)
Could have caused harm · This affected 1 resident
3. R13's clinical record revealed:
5/24/24 - R13 was admitted to the facility after being hospitalized .
5/30/24 - R13's admission MDS assessment stated that she had a moderate cognitive impairment.
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3. R13's clinical record revealed:
5/24/24 - R13 was admitted to the facility after being hospitalized .
5/30/24 - R13's admission MDS assessment stated that she had a moderate cognitive impairment.
6/7/24 at 6:47 PM - A physician's order by E5 (NP) discontinued R13's Flomax medication with a diagnosis incorrectly listed as benign prostatic hyperplasia (BPH). There was no evidence in R13's clinical record that F1 (R13's POA) was notified of this medication change.
6/9/24 at 6:45 PM - A physician's order by E5 (NP) discontinued R13's Primidone medication with a diagnosis incorrectly listed as depression. There was no evidence in R13's clinical record that F1 was notified of this medication change.
6/28/24 at 10:35 AM - During an interview, F1 confirmed that she was R13's Power of Attorney for Care. F1 confirmed that she was not notified that E5 (NP) discontinued R13's Flomax medication prescribed for urinary retention and the Primidone medication as F1 stated it was prescribed for R13's tremors.
6/28/24 at 11:30 AM - Finding was reviewed with E2 (DON) and E3 (ADON).
7/2/24 at 2:15 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), E4 (Clinical Specialist) and two State of DE Ombudsmen (via telephone).
2. Review of R4's clinical record revealed:
1/21/24 - R4 was admitted to the facility.
1/23/24 - R4 participated in his Care Plan conference and signed his Care Plan Conference Summary dated 1/23/24.
4/26/24 - R4's quarterly Minimum Data Set (MDS) assessment was completed.
The facility was not able to produce any documentation of R4 participating in any other Care Plan conferences.
6/28/24 12:20 PM - During an interview, E4 (Corporate CNS) stated, The facility did not do a care plan meeting in April with [R4]. We are scheduling one ASAP. We did not update the care plan in April because we didn't have a care conference.
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 F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation and interview, it was determined that for three (R19, R33 and R45) residents reviewed, the facility failed to ensure that the call bells were within their reach on three observed ...
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Based on observation and interview, it was determined that for three (R19, R33 and R45) residents reviewed, the facility failed to ensure that the call bells were within their reach on three observed occasions. Findings include:
1. Review of R19's medical records revealed:
4/2/2016 - R19 was admitted to the facility with diagnoses including shortness of breath, asthma, and congestive heart failure.
517/24 - R19's significant change MDS assessment documented a BIMS score of 14 (fourteen), indicating no cognitive impairment.
6/24/24 10:15 AM - R19 was observed lying in bed. The bell was observed on the floor near the head of the bed.
6/24/24 11:30 AM - R19 was observed lying in bed. The call bell was observed on the floor near the head of the bed.
6/24/24 1:00 PM - R19 was observed lying in bed. The call bell continued to be on the floor near the head of the bed.
6/24/24 1:10 PM - The surveyor asked R19 if she used the call bell to let the staff know if she needed assistance, R19 stated, Yes, where is my call bell?.
2. Review of R33's clinical records revealed:
11/30/23 - R33 was admitted to the facility with diagnoses including acute respiratory failure, congestive heart failure and chronic pain.
6/24/24 - R33's quarterly MDS assessment documented a BIMS score of 14, indicating no cognitive impairment.
6/24/24 10:30 AM - R33 was observed sitting in the wheelchair in her room. The call bell was observed lying on the floor behind the wheelchair.
6/24/24 12:30 PM - R33 was observed sitting in the wheelchair in her room. A CNA brought R33's lunch. The call bell was observed lying on the floor behind the wheelchair.
6/24/24 1:30 PM - R33's call bell continued to be on the floor behind the wheelchair.
6/24/24 1:45 PM - The surveyor asked R33 if she used the call bell to let the staff know if she needed assistance, R33 stated, Yes.
3. Review of R45's clinical records revealed:
6/23/23 - R45 was admitted to the facility with diagnoses including heart disease, depression, dementia, and muscle weakness.
6/21/24 - R45's annual MDS assessment documented a BIMS score of 00, indicating severe cognitive impairment.
6/24/24 10:35 AM - R45 was observed lying on the bed. The call bell was on the floor behind the bed.
6/24/24 11:35 AM - R45 was observed lying on the bed. The call bell was on the floor behind the bed.
6/24/24 1:35 PM - R45 observed lying on the bed. The call bell continued to be
on the floor behind the bed.
6/24/24 1:50 PM - The surveyor asked R45 if she used the call bell to get the staff's assistance, R45 stated, Yes.
6/24/24 2:00 PM - Findings were confirmed with E3 (ADON).
Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON) E3 (ADON), E4 (Clinical Specialist), E32 (Corporate PT) and State of DE Ombudsman (via telephone).
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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F609 Report Allegation of Abuse- Based on record review and Interviews, it was determined that for one (R28) out of two resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F609 Report Allegation of Abuse- Based on record review and Interviews, it was determined that for one (R28) out of two residents reviewed for Abuse, the facility failed to report R28's allegation of abuse within the two hour time frame. Findings include:
10/15/16 - R28 was admitted to the facility.
12/28/23- R28's quarterly MDS assessment documented a BIMS score of 7, which was reflective of moderate cognitive deficit.
1/23/24 6:30 PM - While providing care to R28, E37 (CNA) noted a left forearm skin tear, which E37 reported to E38 (LPN).
1/24/24 - While investigating R28's left forearm skin tear of unknown origin, R28 stated that the CAN hurt her ( causing the skin tear) and she (R28) doesn't know why the CAN wants to hurt her.
1/24/24 - R28 was care planned for making false accusations.
1/24/24 4:12 PM - The allegation of abuse was reported to the State agency.
This allegation of abuse was reported to the State agency twenty-two hours after the incident was [NAME] to the attention of facility staff.
6/28/24 10:48 AM - During an interview, E3 (ADON) stated, The reason it was not reported until late was that [ E38] (LPN) did not report the allegation to management until 1/24/24. She was counseled in writing and educated about reporting all allegations of abuse immediately.
Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON), E3 (ADON), E4 (Clinical Specialist) and two State of DE Ombudsmen (via telephone).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined that for one (R5) out of one resident reviewed for hospitalization, the facility failed to notify the resident and the resident's representative...
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Based on record review and interview, it was determined that for one (R5) out of one resident reviewed for hospitalization, the facility failed to notify the resident and the resident's representative in writing of R5's transfer to the hospital, including the reason for the transfer. Findings include:
Review of R5's clinical record revealed:
6/13/23 - R5 was admitted to the facility.
5/15/24 - R5 was transferred to the hospital because of chest pain. R5 was admitted to the hospital and was discharged back to the facility on 5/21/24.
6/27/24 2:20 PM - During an interview, E3 stated that the facility's process for hospital transfer communications is to provide verbal communication to resident representatives when residents are transferred to the hospital, not written communication. R5's representative would not have received written communication related to E5's 5/15/24 transfer.
Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON), E3 (ADON), E4 (Clinical Specialist), and State of DE Ombudsmen (via telephone).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected 1 resident
Based on record review and interviews, it was determined that for one (R44) out of seventeen reviewed for Resident Assessments, the facility failed to assess R44 no less than once every three months. ...
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Based on record review and interviews, it was determined that for one (R44) out of seventeen reviewed for Resident Assessments, the facility failed to assess R44 no less than once every three months. Findings include:
11/14/23 - R44 was admitted to the facility.
1/3/24 - R44's admission Minimum Data Set (MDS) assessment was completed.
1/29/24 - R44 was hospitalized .
1/30/24 - R44 was re-admitted to the facility.
2/6/24 - R44's admission MDS was completed.
As of 6/26/24, there were no other MDS assessments completed for R44. There has been more than 141 days since the last MDS assessment.
6/27/24 1:26 PM - During an interview, E33 (MDS coordinator) confirmed that R44 was past due for a quarterly MDS assessment. E33 stated, I'm not sure why the system did not flag him.
Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON), E3 (ADON), E4 (Clinical Specialist) and two State of DE Ombudsmen (via telephone).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that for two (R21, R22) out of seventeen residents reviewed for Resident...
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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 two (R21, R22) out of seventeen residents reviewed for Resident Assessments, the facility failed to ensure accuracy of the assessments. Findings include:
1. Review of R21's clinical record revealed:
8/10/19 - R21 was admitted to the facility with diagnoses, including but not limited to, Parkinsonism, epilepsy and hypertension.
5/3/24 - R21's quarterly Minimum Data Set (MDS) assessment was completed and failed to document in Section I Parkinson's disease as one of R21's diagnoses.
6/27/24 1:21 PM - During an interview, E33 (MDS Coordinator) confirmed that the diagnosis of Parkinson's was not in R21's MDS dated [DATE] and that it should have been included.
2. Review of R22's clinical record revealed:
4/27/21 - R22 was admitted to the facility with diagnoses, including but not limited to, atrial fibrillation, heart failure and dementia.
5/1/24 R22's annual MDS assessment was completed and documented in Section I pneumonia as one of R22's active diagnoses.
The facility was unable to produce evidence that verified coding pneumonia as an active diagnosis for R22 as there was no evidence of this diagnosis in R22's chart for this quarter.
6/28/24 12:06 PM - During an interview, E4 (Clinical Specialist) stated, The pneumonia documented on the 5/1/24 MDS was a mistake. [R22] did not have pneumonia during that period of time. We are fixing the MDS and resubmitting it.
Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON), E3 (ADON), E4 (Clinical Specialist) and two State of DE Ombudsmen (via telephone).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that for one (R62) out of two reviewed for PASARR, the facility failed t...
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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 (R62) out of two reviewed for PASARR, the facility failed to secure R62's PASARR upon admission on [DATE]. Findings include:
4/8/24 - R62 was admitted to the facility with diagnoses including Parkinson's, diabetes and bipolar disorder.
4/21/24 - R62's Minimum Data Set (MDS) assessment documented bipolar disorder as one of R62's diagnoses in Section I.
6/27/24 1:30 PM - During an interview, E2 (DON) stated, We haven't been able to locate that PASARR. We are looking. R62 came here from an AL (Assisted Living) community.
6/28/24 8:52 AM - During an interview, E2 stated, We still have not been able to find her (R62's) PASARR. I am going to request it online again and see if they will send me a duplicate.
7/2/24 2:10 PM - E2 confirmed that the facility has not located R62's PASARR document.
Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON), E3 (ADON), E4 (Clinical Specialist) and two State of DE Ombudsmen (via telephone).
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
Based on record review and interviews, it was determined that for two (R54 and R172) out of four reviewed for care plans, the facility failed to develop and implement a person-centered care plan. Find...
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Based on record review and interviews, it was determined that for two (R54 and R172) out of four reviewed for care plans, the facility failed to develop and implement a person-centered care plan. Findings include:
1. Review of R54's clinical record revealed:
5/16/23 - R54 was admitted to the facility with diagnoses, including but not limited to, multiple sclerosis and stroke affecting R54's right side.
5/22/24 - E36 (DO) ordered, Apply resting hand splint to righthand at the end of 3-11 shift and remove at the end of 11-7 shift.
Review of R54's care plan revealed no interventions/tasks regarding R54's righthand splint.
The facility was not able to produce any documentation of the righthand splint on R54's care plan.
6/28/24 8:55 AM - During an interview, E2 (DON) confirmed that R54's care plan did not include any mention of R54's righthand splint. We can add it into the care plan if that is what we need to do.
2. Review of R172's clinical records revealed:
11/14/21 - R172 was admitted to the facility.
1/24/24 - R172's quarterly MDS assessment documented that the resident was completely dependent on staff for all activities of daily living including turning, repositioning, showers, and transfers. R172's BIMS score was 6, which indicated severe cognitive impairment.
7/1/24 9:20 AM - A review of R172's Kardex (electronic document for the aides to inform the staff of the residents' care needs) lacked information of how many staff members were needed to assist with turning and repositioning in bed. A review of R172's care plan also lacked documentation of how many staff members were needed for turning and repositioning in bed.
7/1/24 1:15 PM - During an interview, E5 (Unit Manager) stated, Physical Therapy determines how many staff members are needed for transfers and turning and repositioning. This information is then communicated to nursing, the order is obtained from the doctor, and the Kardex and the care plan are updated.
7/1/24 2:17 PM - During an interview, E6 (Physical Therapy Director) stated, The residents are seen on admission and evaluated for bed mobility and transfer status. This information is given to nursing for the resident's records. E6 failed to give the surveyor any documents of R172's evaluation and recommendations for bed mobility upon request.
7/1/24 2:30 PM - During an interview, E14 and E19 (CNAs), stated that they look at the Kardex for information on residents' care including bed mobility and transfers.
The facility failed to evaluate and develop a care plan for how many staff members were needed for R172's turning and repositioning, and that this information was documented on the Kardex status for staff to care for her safely.
Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON) E3 (ADON), E4 (Clinical Specialist), E32 (Corporate PT) and State of DE Ombudsman (via telephone).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined that for one (R5) out of one resident reviewed for care planning, the facility interdisciplinary team failed to review and revise R5's care plan...
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Based on record review and interview, it was determined that for one (R5) out of one resident reviewed for care planning, the facility interdisciplinary team failed to review and revise R5's care plan after a comprehensive assessment was completed. Findings include:
Review of R5's clinical record revealed:
6/13/23 - R5 was admitted to the facility.
5/28/24 - A Minimum Data Set (MDS) comprehensive assessment was documented for R5, which included a newly assessed care area for dehydration.
6/13/24 - A care plan meeting was held with the interdisciplinary team to review R5's care needs.
6/25/24 - A review of R5's electronic medical record (Emr) care plan revealed the lack of a care plan problem for dehydration.
6/28/24 10:40 AM - During an interview, E33 (MDS Coordinator) confirmed that dehydration was a new care area identified for R5, but that R5's care plan lacked a problem for dehydration after the care plan meeting was held on 6/13/24.
Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON), E3 (ADON), E4 (Clinical Specialist), and State of DE Ombudsmen (via telephone).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on clinical record review and interview, it was determined that for three (R5, R223 and R270) out of twenty-one residents reviewed for care planning, the facility failed to meet professional sta...
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Based on clinical record review and interview, it was determined that for three (R5, R223 and R270) out of twenty-one residents reviewed for care planning, the facility failed to meet professional standards of the Delaware Board of Nursing Scope of Practice by having LPNs complete the admission assessment and admission progress note.
Findings include:
Delaware State Board of Nursing - RN, LPN and NA/UAP Duties 2024 . admission Assessments * - RN . *= Once a care plan is established, the LPN may do assessments .
The Braden Scale is a validated tool designed to assess a patient's risk of developing pressure ulcers. National Library of Medicine, Nov. 21, 2022.
1. Review of R5's clinical record revealed:
6/13/23 - R5 was admitted to the facility.
A review of the clinical record revealed the following 6/13/23 facility admission assessments conducted by E38 (LPN): Wander Risk Evaluation, Pain evaluation, Bladder and Bowel Continence evaluation, Trauma Informed Screening, Functional Abilities and Goals-Admission, Baseline Care Plan, Braden (scale for predicting pressure ulcer risk) evaluation and a Skin and Wound-Total Body Skin Assessment. The admission progress note was completed by E37 (LPN).
2. Review of R270's clinical record revealed:
6/19/24 - R270 was admitted to the facility.
A review of the clinical record revealed the following 6/19/24 facility admission assessments conducted by E39 (LPN): Elopement Evaluation, Fall Risk Evaluation, Functional Abilities and Goals-Admission, Baseline Care Plan, Braden (scale for predicting pressure ulcer risk) evaluation, Clinical admission and the admission progress note.
6/22/24 - R223 was admitted to the facility.
A review of the clinical record revealed the following 6/22/24 facility admission assessments conducted by E12 (LPN) and E39 (LPN): Dehydration Risk Evaluation, Elopement Risk Evaluation, Fall Risk Evaluation, Braden (scale for predicting pressure ulcer risk) evaluation, Functional Abilities and Goals-Admission, Baseline Care Plan, Clinical Admission. The admission progress note was written by E39.
7/1/24 - 2:35 PM - During an interview, E3 (ADON) confirmed that LPN's do admission assessments on new residents.
Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON), E3 (ADON), E4 (Clinical Specialist), and State of DE Ombudsmen (via telephone).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, it was determined that for 1 (R45) resident out of 2 (two) reviewed for ADLs, the facility failed to ensure that R45 received appropriate care to ma...
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Based on observation, interview, and record review, it was determined that for 1 (R45) resident out of 2 (two) reviewed for ADLs, the facility failed to ensure that R45 received appropriate care to maintain good grooming. Findings include:
Review of R45's clinical records revealed:
6/23/23 - R45 was admitted to the facility with diagnoses including heart disease and muscle weakness.
7/28/23 - R45's care plan documented, .Please check my nail length, clean and trim on bath day and as necessary .
6/21/24 - R45's annual MDS assessment documented a BIMS of 00, indicating severe cognitive impairment, and was dependent on staff for bathing, grooming and hygiene.
6/24/24 10:30 AM - R45 was observed in bed, her fingernails on both hands were long and dirty.
6/24/24 12:30 PM - R45 was observed feeding herself with a fork. R45's fingernails continued to be long and dirty.
6/25/24 10:00 AM - R45 was observed with long, dirty fingernails on both hands on both hands.
6/26/24 8:30 AM - R45 was observed feeding herself with a fork, then picked up an item and put it in her mouth. Her fingernails continued to be long and dirty on both of her hands. The surveyor asked R45 if she would accept having her nails cleaned and trimmed, R45 stated, Yes.
6/26/24 2:30 PM - Findings were confirmed with E3 (ADON) and E4 (Clinical Specialist).
Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON) E3 (ADON), E4 (Clinical Specialist), E32 (Corporate PT) and State of DE Ombudsman (via telephone).
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that for one (R18) out of twenty-five residents reviewed for Quality of ...
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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 (R18) out of twenty-five residents reviewed for Quality of Care, the facility failed to ensure the resident received treatment and care in accordance with professional standards as evidenced by ordering a regular diet when discharge instructions recommend a low potassium diet. Findings include:
5 STAGES OF KIDNEY DISEASE
Stage 1 CKD (chronic kidney disease): Mild kidney damage, GFR 90 or higher
Stage 2 CKD: Mild loss of kidney function, GFR 60-89
Stage 3a & 3b CKD: Mild to severe loss of kidney function, GFR 30-59
Stage 4 CKD: Severe loss of kidney function, GFR 15-29
Stage 5 CKD: Kidney failure or close to failure, GFR less than 15
Review of R18's clinical record revealed:
7/3/24 11:23 AM - The hospital Interagency Discharge orders stated, .Discharge diagnoses: . CKD stage 4, GFR (glomerular filtration rate) 15-29 ml/min Diet: .Soft and Bite-sized diet, Thin liquids, Low Potassium .
7/3/24 - R18 was admitted to the facility with diagnoses including but not limited to, chronic kidney disease with hypertensive heart failure and diabetes.
7/3/24 9:35 PM -E5 (RN) entered a verbal order from E4 (DO) for a regular diet in R18's electronic medical record (EMR). This order was electronically signed by E4 (DO).
7/10/24 - E7 (contracted dietician) completed R18's Dietary/Nutrition profile. This assessment failed to acknowledge R18's diagnosis of stage 4 kidney disease and his need for a low potassium diet.
7/17/24 - R18 was transferred to the hospital for heart failure and did not return to the facility.
9/10/24 2:10 PM - During an interview, E6 (dietician) stated, I was on vacation at that time. [E7] was a contract dietician here to cover my vacation.
For the duration of R18's admission [DATE] to 7/17/24), the facility was unable to provide evidence that R18 was ever placed on a low potassium diet.
9/10/24 3:00 PM - The findings were reviewed with E1 (NHA), E2 (ADON) and E3 (Regional CNS) at the exit conference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
Based on record review and interviews, it was determined that for one (R4) out of one reviewed for Communication-Sensory, the facility failed to ensure R4 received proper treatment to assist/ maintain...
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Based on record review and interviews, it was determined that for one (R4) out of one reviewed for Communication-Sensory, the facility failed to ensure R4 received proper treatment to assist/ maintain hearing abilities as evidenced by not submitting a referral for a hearing consult despite R4 being severely hard of hearing. Findings include:
1/21/24 - R4 was admitted to the facility.
1/21/24 - E36 (DO) ordered in R4's electronic medical record (EMR), May have dental, podiatry, ophthalmology, audiology consult.
6/24/24 5:20 PM - During an interview, R4 stated, You have to speak in my right ear; that is the good one. I have difficulty hearing. I think it is wax buildup but I would like to have my hearing checked.
6/27/24 10:40 AM - During an interview, E26 (LPN) stated, [R4] has really bad hearing. That is why we keep his door closed because he blasts the volume on his TV and it bothers the other residents.
6/28/24 9:42 AM - During an interview, when asked about R4's hearing E35 (CNA) stated, Oh that is him. He has always been hard of hearing. That is why his TV is on the max (volume) and his door (to his room) is kept shut, because his TV is so loud.
The facility was unable to produce any documentation regarding treatment or a referral for R4's hearing deficit.
6/28/24 10:41 AM - During an interview, E32 (Corporate PT) stated, We'll put him on the list for Audiology. Not sure if it is a carve out (sic) but we won't base it on his insurance. He may just need an amplifier.
Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON), E3 (ADON), E4 (Clinical Specialist) and two State of DE Ombudsmen (via telephone).
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 F0728
(Tag F0728)
Could have caused harm · This affected 1 resident
Based on a review of documents and interviews, the facility failed to ensure that nursing staff demonstrated competence through satisfactory participation in a State approved nurse aide training and c...
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Based on a review of documents and interviews, the facility failed to ensure that nursing staff demonstrated competence through satisfactory participation in a State approved nurse aide training and competency evaluation program. Findings include:
7/1/24 - A review of facility documentation revealed that E15 (CNA Agency) had worked at the facility on the following dates:
9/23/23
9/24/23
10/28/23
12/19/23.
7/1/24 4:10 PM - During an interview, E3 (ADON) and E41(Consulting DON) stated that they were unable to produce a valid CNA certification from E15's employment agency.
7/2/24 12:07 PM - Validation was received from DHSS/DHCQ that E15's did not hold a Delaware CNA certificate and is not on the State of DE CNA Registry.
Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON), E3 (ADON), E4 (Clinical Specialist), and State of DE Ombudsmen (via telephone).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
Based on a review of facility documents and interview, it was determined that the facility failed to complete a performance review every twelve months for one (E16) out of five nurse aides. Findings i...
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Based on a review of facility documents and interview, it was determined that the facility failed to complete a performance review every twelve months for one (E16) out of five nurse aides. Findings include:
The facility was provided a list of five names of CNAs to provide documentation of the completion of annual performance evaluations.
7/1/24 - A review of E16's performance evaluation documentation revealed the lack of an 2024 annual performance evaluation since E16 was hired on 2/22/23.
7/1/24 12:30 PM - During an interview, E21 (HR) confirmed that E16 has not had an annual performance evaluation since E16 was hired on 2/22/23.
Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON), E3 (ADON), E4 (Clinical Specialist), and State of DE Ombudsmen (via telephone).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, it was determined that for one (R54) out of six reviewed for Pharmacy Services, the facil...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, it was determined that for one (R54) out of six reviewed for Pharmacy Services, the facility failed to ensure that the pharmacy services provided safe and effective medication use. Findings include:
Facility Medication Regimen Review (MRR) Policy Statement- the consultant pharmacist reviews the medication regimen of each resident monthly .5. The MRR involves a thorough review of the resident's medication record to prevent . d. inadequate monitoring for adverse consequences .g. incorrect medications, administration times or dosage forms . May 2019
Combination Use of Clopidogrel and Proton Pump Inhibitors Increase Major Adverse Cardiovascular Events ([NAME]) in patients with Coronary Artery Disease: A meta-Analysis- In conclusion, the result of out meta-analysis supports the notion that the combination use of clopidogrel and PPIs (such as protonix) will increase the risk of [NAME] in patients with coronary artery disease, which is in accordance with pharmacokinetic and pharmacodynamic studies. Journal of Cardiovascular Pharmacology and Therapeutics 2017, Vol 22(2), 142-152.
5/16/23 - R54 was admitted to the facility with diagnoses, including but not limited to, multiple sclerosis and stroke affecting R54's right side.
5/22/24 - E36 (DO) ordered, Clopidogrel bisulfate tablet 75 mg via G-tube one time a day for prevent blood clot.
5/22/24 _ E36 (DO) ordered, Protonix tablet delayed release 40 mg- give 40 mg via G-tube one time a day for GERD (Gastroesophageal reflux disease).
The facility failed to ensure that the pharmacist assured the correct formulation of the medication protonix was utilized. A delayed released tablet should not be administered via a G-tube.
5/28/24 - E39 (Consultant Pharmacist) completed a Medication Regimen Review (MRR) and found no irregularities.
6/18/24 - E39 (Consultant Pharmacist) completed a Medication Regimen Review (MRR) and found no irregularities.
6/25/24 - Review of R54's Medication Administration Record (MAR) for June 2024 revealed protonix 40mg was scheduled to be given at 7:30 AM and clopidogrel 75 mg was scheduled to be given at 8AM.
The facility failed to ensure that the pharmacist defined a schedule for administering medications (protonix and clopidogrel) that prevented potential significant medication interactions.
6/25/24 - Review of R54's June 2024 order set revealed a pharmacy warning notation next to the protonix and clopidogrel orders that stated, Coadministration of pantoprazole and clopidogrel may increase the risk of major adverse cardiovascular events.
6/26/24 8:05 AM - E26 (LPN) administered protonix and clopidogrel to R54 via her G-tube.
7/2/24 11:00 AM - E4 (Clinical specialist) confirmed that the scheduled timings of the protonix and clopidogrel needed to be changed to allow more time between these medications administrations. E4 also stated, [R54] should be on a different formulation of protonix (rather than a delayed release tablet) since the medication was being crushed and administered via a G-tube.
Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON), E3 (ADON), E4 (Clinical Specialist) and two State of DE Ombudsmen (via telephone).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, it was determined that for one (R22) out of four residents reviewed for Advanced Directiv...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, it was determined that for one (R22) out of four residents reviewed for Advanced Directives, the facility failed maintain accurately documented medical records regarding R22's code status. Findings include:
[DATE] - R22 was admitted to the facility with diagnoses, including but not limited to, atrial fibrillation, heart failure and dementia.
[DATE] - E36 (DO) completed a Delaware Medical Orders for Scope of Treatment (DMOST) with F2 (R22's son/POA), which stated that R22 was to have CPR/ attempt resuscitation.
[DATE] - E36 (DO) ordered, CPR- FULL code status in R22 's EMR.
[DATE] - E36 (DO) documented in R22's EMR a progress note that stated, .History-Code Status List: Full scope of treatment .Advanced Care Planning details: Pt and family agreed to discuss advance directive.
Patient and family would like to remain DO NOT RESUSCITATE (DNR) with no artificial nutrition or hydration through conduit.
Within the same note, there is documentation of both a full code status and a DNR status for R22.
[DATE] - E36 (DO) documented in R22's EMR a progress note that stated, .History-Code Status List: Full code .Advanced Care Planning details: Pt and family agreed to discuss advance directive. Patient and family would like to remain DO NOT RESUSCITATE (DNR) with no artificial nutrition or hydration through conduit.
Within the same note, there is documentation of both a full code status and a DNR status for R22.
[DATE] - R22's annual MDS documented a Basic Inventory of Mental Status (BIMS) score of 15, which reflected normal cognition.
[DATE] 3:45 PM - During an interview, R22 stated that he wanted CPR and everything done.
[DATE] 11:11 AM - During an interview, when shown the conflicting documentation in E36's [DATE] and [DATE] progress notes, E4 (Clinical specialist) stated, Yeah, we need to get that straightened out. [E36]'s note states that R22 is a full code but then later in the notes it is documented that the patient and the family would like to remain a DNR. That is confusing. But the order in the EMR and the DMOST match. Both state that R22 is a full code.
Findings were reviewed during the exit conference on [DATE] at 2:15 PM with E1 (NHA), E2 (DON), E3 (ADON), E4 (Clinical Specialist) and two State of DE Ombudsmen (via telephone).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected 1 resident
Based on record review and interviews, it was determined that the facility failed to have a designated infection preventionist with specialized training in infection prevention and control. Findings i...
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Based on record review and interviews, it was determined that the facility failed to have a designated infection preventionist with specialized training in infection prevention and control. Findings include:
May 2024 - Review of the Facility Assessment, which was dated May 2024, revealed on page 5, the Infection Preventionist was the ADON (E3).
6/27/24 1:28 PM - During an interview, E33 (RN/MDS Coordinator) stated, I am not the Infection Preventionist. It is [E3] (ADON).
6/27/24 1:56 PM - During an interview, E4 (Clinical Specialist) stated, That's not right. [E2] (DON) is the facility Infection Preventionist. [E3] cannot be the Infection preventionist; she is not certified.
7/1/24 10:46 AM - During an interview, E4 (Clinical Specialist) stated, Infection control is a group effort while we try to fill the role. We had someone and then at the last minute, they turned down the role. [E2] (DON), [E3] (ADON) and [E33] (RN/MDS Coordinator) work on it together.
7/1/24 12:26 PM - The facility has not been able to provide a copy of E2's Infection preventionist training certificate as it was sent to her previous place of employment's email and she is unable to retrieve it. The facility did not provide a copy of E33's Infection Preventionist training certificate.
7/2/24 11:09 AM - During an interview, E4 (Clinical Specialist) stated, [E2] (DON) is still trying to get a copy of her certification from [previous place of employment]. But we changed the name of the Infection preventionist on the Facility Assessment to [E33] (RN/MDS Coordinator), who is certified.
7/2/24 11:49 AM- The facility provided a copy of the Facility Assessment Tool page 5 which now stated E33 (RN/MDS Coordinator) was the facility Infection Preventionist.
Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON), E3 (ADON), E4 (Clinical Specialist) and two State of DE Ombudsmen (via telephone).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected 1 resident
Based on review of facility documentation and interview, it was determined that the facility failed to provide required in-service training (12 hours per year) for five out of five CNAs reviewed. Addi...
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Based on review of facility documentation and interview, it was determined that the facility failed to provide required in-service training (12 hours per year) for five out of five CNAs reviewed. Additionally, the facility failed to provide evidence of resident abuse prevention training for the five CNAs reviewed. Findings include:
The facility was provided a list of five names of CNAs to provide documentation of the required 12 hours per year of CNA in-service training.
7/1/24 - A review of facility documentation submitted for staff training lacked evidence that E16, E17, E18, E19 and E20 met the 12 hours of annual in-service training required, including resident abuse prevention training.
7/2/24 10:00 AM - During an interview E2 (DON) stated that the facility was unable to provide documentation of the total number of required training hours, including resident abuse prevention training, for E16, E17, E18, E19 and E20.
The facility failed to provide 12 hours of required annual in-service training's for five out of five staff CNA's.
Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON), E3 (ADON), E4 (Clinical Specialist), and State of DE Ombudsmen (via telephone).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, it was determined that for seven (R13, R22, R33, R34, R47, R54, R270) out of seventeen r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, it was determined that for seven (R13, R22, R33, R34, R47, R54, R270) out of seventeen residents reviewed for Infection Control, it was determined that the facility failed to establish and maintain an infection prevention and control program that included Enhanced Barrier Precautions (EBP). Additionally, it was determined that for 3 (three) R34, R47, R270 residents reviewed for urinary catheter care the facility failed to ensure a safe and sanitary process regarding urinary collection bags. Findings include:
Facility Enhanced Barrier Precautions (EBP) Policy Statement- Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents .Policy Interpretation and Implemenetation 2. EBPs employ targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gowns are applied before performing the high-contact resident care activity (as opposed to before entering the room) .3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: .d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube .); .10. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required . May 4, 2024
1.Review of R13's clinical record revealed:
5/24/24 - R13 was admitted to the facility into room [ROOM NUMBER]b.
6/19/24 - R13's hospital records documented prior MDROs infections and a diagnosis of extended spectrum beta-lactamase (ESBL) urinary tract infection (UTI).
R13's medical history indicated that EBPs would be required.
There was no evidence of EBP signage or personal protective equipment (PPE) outside R13's room.
2. Review of R22's clinical record revealed:
4/27/21 - R22 was admitted to the facility into room [ROOM NUMBER]a.
6/26/24 9:10 AM- Observation of the wound team rounding and providing care to R22's left heel resolving wound without any gown. Gloves were worn.
R22's medical diagnosis list in his electronic medical record (EMR) documented ICD 10 code Z16.12 Extended spectrum beta lactamase (ESBL) resistance of his left heel wound. R22's medical record also documented a history of methicillin-resistant Staphylococcus aureus (MRSA) infection.
Both of these infections qualified as MDROs and therefore, R22 required EBP.
3. Review of R33's clinical record revealed:
11/30/23 - R33 was admitted to the facility into room [ROOM NUMBER]b.
12/28/23 - R33's medical record documented a urine culture with Escherichia (E) coli ESBL infection.
4/28/24 - R33's medical record documented a second urine culture with E.coli ESBL.
Review of R33's hospital records revealed a MRSA positive culture while hospitalized in November 2023.
Both of these infections (E.coli ESBL UTI and MRSA) qualified as MDROs and therefore, R33 required EBP.
There was no evidence of EBP signage or personal protective equipment (PPE) outside R33's room.
4. Review of R34's clinical record revealed:
5/4/23 - R34 was admitted to the facility into room [ROOM NUMBER]b.
5/10/24 - R34's medical record documented a urine culture with Klebsiella pneumoniae ESBL.
5/10/24 - E36 (DO) ordered in R34's EMR, Document indwelling foley catheter output Q (every) shift related to urinary retention.
Both the infection (Klebsiella pneumoniae ESBL UTI), which was a MDRO, and the indwelling foley catheter (medical device) were indications for EBP; therefore, R34 required EBP.
There was no evidence of EBP signage or personal protective equipment (PPE) outside R34's room.
5. Review of R47's clinical record revealed:
2/12/23 - R47 was admitted to the facility into room [ROOM NUMBER]a.
3/7/24 - E36 (DO) ordered in R47's EMR, Check foley catheter Q shift for clogging.
5/29/24 - R47's medical record documented a urine culture with Vancomycin resistant enterococcus faecalis (VRE) and MRSA.
Both of the infections (VRE and MRSA UTIs), which was a MDRO, and the indwelling foley catheter (medical device) were indications for EBP; therefore, R47 required EBP.
There was no evidence of EBP signage or personal protective equipment (PPE) outside R47's room.
6. Review of R54's clinical record revealed:
5/16/23 - R54 was admitted to the facility into room [ROOM NUMBER]b.
5/16/23 - E36 (DO) ordered in E54's EMR, Check placement of tube (G-tube) and residual every shift .
6/27/24 8:05 AM - Observation of E26 (LPN) administering R54's medications via her G-tube without utilizing EBP. E26 did have gloves on.
The presence of the G-tube (feeding tube) was an indication for R54 to be on EBP.
There was no evidence of EBP signage or personal protective equipment (PPE) outside R54's room.
7. Review of R270's clinical record revealed:
6/19/24 - R270 was admitted to the facility into room [ROOM NUMBER]b from another facility. R270's transfer paperwork listed a diagnosis of history of ESBL infection.
6/16/24 - E36 (DO) ordered in R270's EMR, Empty foley catheter bag every shift.
The presence of the indwelling foley catheter (medical device) and history of ESBL infection were both indications for R270 to be on EBP.
6/27/24 2:37 PM - During an interview, E43 stated that she does not wear any protective clothing or coverings other than gloves when emptying the foley catheter bag for R 270.
6/27/24 2:56 PM - During an interview, E26 (LPN) stated, We do use yellow gowns at times. If the resident is on precautions, the facility puts a sign up. I don't get a lot of residents on precautions because this is the long-term care wing of the facility.
7/1/24 10:52 AM - Observation of rooms 508b, 512b, 514b, 615b, 707a, and 712b revealed no signage stating the residents in those rooms were on EBPs.
7/2/24 10:35 AM - A poll of all five surveyors revealed that at no point during the previous six days of the survey had any surveyor observed any staff providing direct patient care to any residents while utilizing EBP (wearing a yellow gown and gloves).
7/2/24 11:04 AM - During an interview, E4 (Clinical Specialist) stated,
We are doing EBP. We list it on [the EMR] next to the resident's name. E4 pulled up a resident on the EMR to show the surveyor the EBP order. E4 stated, Oh my God, it's not there and there is no order (pointing to the EMR). We are doing it our other two facilities.
8. Review of R34's clinical records revealed:
5/4/24 - R34 was admitted to the facility with diagnoses including adult failure to thrive, seizure, and neurogenic bladder.
5/10/24 - R34's clinical records included, Ensure that tubing and dignity bag are off the floor.
5/13/24 - R34's care plan included, Privacy bag at all times.
6/24/24 10:30 AM - R34 was observed lying in the bed, an uncovered, undated urinary collection bag with yellow urine was observed on the floor on the left side of the bed. An undated/unlabeled urinary collection container was observed on the toilet seat of the shared bathroom.
6/24/24 1:30 PM - R34 was observed lying in the bed, the uncovered, undated urinary collection bag with yellow urine continued to be on the floor on the left side of the bed.
An undated/unlabeled urinary collection container was observed on the toilet seat of the shared bathroom.
6/25/24 - 10:30 AM R34 was observed lying in the bed, an uncovered, undated urinary collection bag with yellow urine was observed on the right side of the bed on the floor. An undated/unlabeled urinary collection container was observed on the toilet seat of the shared bathroom.
6/25/24 - 2:30 PM: R34 was observed lying in the bed, an uncovered, the undated urinary bag with yellow urine continued to be observed on the right side of the bed on the floor. An undated/unlabeled urinary collection container was observed on the toilet seat of the shared bathroom.
6/25/24 3:00 PM - Findings were confirmed with E3 (ADON) and E4 (Clinical Specialist) stated.
9. Review of R47's clinical records revealed:
1/6/22 - R47 was admitted to the facility with diagnoses including urinary tract infections, neurogenic bladder, hypertension, and seizure disorder.
5/10/23 - R47's clinical records documented, Check tubing for kinks, and privacy bag at all times, secure catheter to reduce friction.
6/24/24 10:30 AM - R47 was observed lying in bed, an undated, uncovered urinary collection bag with yellow urine was observed touching the floor on the left side of the bed. An undated/unlabeled urinary collection container was observed on the grab bar of the bathroom.
6/24/24 2:30 PM - R 47 was observed lying in bed, the undated, uncovered urinary collection bag with yellow urine continued to be touching the floor on the left side of the bed. An undated/unlabeled urinary collection container was observed on the grab bar of the bathroom
6/25/25 10:00 AM - R47 was observed lying in bed, an uncovered, undated urinary collection bag with yellow urine hanging on the right side of the bed and visible from the doorway. An undated/unlabeled urinary collection container was observed on the grab bar of the bathroom
6/25/24 2:30 PM - R47 was observed lying in bed, an uncovered, undated urinary collection bag with yellow urine in a wash basin was on the left side of the bed on the floor.An undated/unlabeled urinary collection container was observed on the grab bar of the bathroom
6/25/24 3:00 PM - Findings were confirmed with E3 (ADON) and E4 (Clinical Specialist).
10. Review of R270's clinical records revealed:
6/19/24 - R270 was admitted to the facility with multiple diagnoses, including obstructive uropathy, and R270 had a foley utinary catheter in place at admission.
The following observations were made on 6/25/24 of R270's foley urinary catheter drainage bag:
10:30 AM - The foley urinary catheter drainage bag was on the facility floor.
11:30 AM - The foley urinary catheter drainage bag was on the facility floor.
11:41 AM - R270 was observed to be wheeled by a CNA the facility shower room with an uncovered foley urinary catheter bag dragging on the floor.
6/25/24 11:41AM - Findings were confirmed with E3 (ADON) and E4 (Clinical Specialist).
Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON) E3 (ADON), E4 (Clinical Specialist) and State of DE Ombudsman (via telephone).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
Based on record review and interview, it was determined that for nine (R4, R13, R18, R19, R33, R45, R51, R60 and R223) out of seventeen residents reviewed for vaccines, the facility failed to document...
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Based on record review and interview, it was determined that for nine (R4, R13, R18, R19, R33, R45, R51, R60 and R223) out of seventeen residents reviewed for vaccines, the facility failed to document in each resident's medical record the administration of the pneumococcal and/or influenza vaccines. Additionally, it was determined that for one (R22) out of seventeen residents reviewed for immunizations, the facility failed to offer R22 an updated pneumococcal vaccine. Findings include:
Vaccinations of Residents Policy Statement- All residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated .All new residents shall be assessed for current vaccination status upon admission .If the resident receives a vaccine, at least the following information shall be documented in the resident's medical record: a. site of administration; b. date of administration; c. lot number of the vaccine (located on the vial); d. expiration date (located on the vial); and e. name of person administering the vaccine . October 2019
Pneumococcal Vaccine Policy Statement- All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections .2. Assessments of pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission .6. For residents who receive the vaccines, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's medical record . October 2019
Influenza Vaccine Policy Statement- All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza . 1. Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents .5. For those who receive the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's medical record .6. A resident's refusal of the vaccine shall be documented on the informed consent for influenza vaccine and placed in the resident's medical record .10 Residents .may obtain their influenza vaccines from their personal physicians. Documentation of previous vaccination should be provided to the facility . October 2019
1. Review of R4's clinical record revealed:
1/21/24 - R4 was admitted to the facility.
2/20/24 - R4 received the PCV20 (pneumococcal 20-valent conjugant) vaccine, which was documented in the DELVAX website.
6/27/24 8:00 PM - Review of R4's electronic medical record (EMR) revealed the PCV20 pneumococcal vaccine that was administered on 2/20/24 was not documented. There also was no documentation of the influenza vaccine that R4 received at the hospital on 1/14/24, which was documented in DELVAX.
2. Review of R13's clinical record revealed:
5/24/24 - R13 was admitted to the facility.
2/20/24 - R13 received the PCV20 vaccine, which was documented in the DELVAX website.
6/27/24 8:00 PM - Review of R13's EMR revealed the PCV20 pneumococcal vaccine that was administered on 2/20/24 was not documented. There also was no documentation of a 2023/24 influenza vaccine or the declination of that vaccine provided by the facility.
3. Review of R18's clinical record revealed:
6/1/22 - R18 was admitted to the facility.
2/20/24 - R18 received the PCV20 vaccine, which was documented in the DELVAX website.
6/27/24 8:00 PM - Review of R18's EMR revealed the PCV20 pneumococcal vaccine that was administered on 2/20/24 was not documented.
4. Review of R19's clinical record revealed:
4/2/16 - R19 was admitted to the facility.
2/20/24 - R19 received the PCV20 vaccine, which was documented in the DELVAX website.
6/27/24 8:00 PM - Review of R19's EMR revealed the PCV20 pneumococcal vaccine that was administered on 2/20/24 was not documented. There also was no documentation of a 2023/24 influenza vaccine or the declination of that vaccine provided by the facility.
5. Review of R33's clinical record revealed:
11/30/23 - R33 was admitted to the facility.
2/20/24 - R33 received the PCV20 vaccine, which was documented in the DELVAX website.
6/27/24 8:00 PM - Review of R33's EMR revealed the PCV20 pneumococcal vaccine that was administered on 2/20/24 was not documented.
6. Review of R45's clinical record revealed:
6/23/23- R45 was admitted to the facility.
2/20/24 - R45 received the PCV20 vaccine, which was documented in the DELVAX website.
6/27/24 8:00 PM - Review of R45's EMR revealed the PCV20 pneumococcal vaccine that was administered on 2/20/24 was not documented.
7. Review of R51'sclinical record revealed:
12/22/22 - R51 was admitted to the facility.
2/20/24 - R51 received the PCV20 vaccine, which was documented in the DELVAX website.
6/27/24 8:00 PM - Review of R51's EMR revealed the PCV20 pneumococcal vaccine that was administered on 2/20/24 was not documented. There also was no documentation of a 2023/24 influenza vaccine or the declination of that vaccine provided by the facility.
8. Review of R60's clinical record revealed:
11/1/23 - R60 was admitted to the facility.
2/20/24 - R60 received the PCV20 vaccine, which was documented in the DELVAX website.
6/27/24 8:00 PM - Review of R51's EMR revealed the PCV20 pneumococcal vaccine that was administered on 2/20/24 was not documented.
9. Review of R223's clinical record revealed:
6/22/24- R223 was re-admitted to the facility.
2/20/24 - R223 received the PCV20 vaccine, which was documented in the DELVAX website.
6/27/24 8:00 PM - Review of R223's EMR revealed the PCV20 pneumococcal vaccine that was administered on 2/20/24 was not documented. There also was no documentation of a 2023 influenza vaccine or the declination of that vaccine provided by the facility.
6/28/24 8:49 AM - During an interview, E4 (Clinical Specialist) stated, We had a pharmacy clinical in February. They came in and vaccinated the residents. They entered the vaccines in DELVAX. So if we put the vaccine dates in PCC under the immunization tab, we will be in compliance, right?
The facility failed to document in the EMR's the dates of pneumococcal vaccines for nine residents and the dates or declinations of influenza vaccines for five residents.
10. Review of R22's clinical record revealed:
Centers for Disease Control and Prevention (CDC) Guidelines for Pneumococcal Vaccine Timing for Adults, 65 years, in order for an adult older than 65 years to be up-to-date/complete with the pneumococcal vaccination, a Prevnar20 (PCV20) vaccine should be administered 1 year after that adult received PCV13. CDC, April 2022
Facility Pneumococcal Vaccine Policy- .upon admission .will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated .For residents who receive the vaccines .will be documented in the resident's medical record . Administration of the pneumococcal vaccine or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. October 2019
4/27/21 - R22 was admitted to the facility with diagnoses, including but not limited to, atrial fibrillation, heart failure and dementia.
6/27/24 -Review of R22's immunizations in the EMR revealed no documentation of a pneumococcal vaccine.
DELVAX, Delaware's online immunization documentation system, documented that R22 received a Prevnar13 (13-valent pneumococcal conjugate) vaccine on 8/27/2015.
The facility was unable to produce documentation of a recent pneumococcal vaccination, a medical contraindication, or a declination declaration for R22.
Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON), E3 (ADON), E4 (Clinical Specialist) and two State of DE Ombudsmen (via telephone).
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0838
(Tag F0838)
Minor procedural issue · This affected most or all residents
F838 Facility Assessment- Based on record review and interview, it was determined that the facility failed accurately update the Facility Assessment Tool, which was created May 2024, with the correct ...
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F838 Facility Assessment- Based on record review and interview, it was determined that the facility failed accurately update the Facility Assessment Tool, which was created May 2024, with the correct name of the Infection Preventionist. Findings include:
6/26/24 11:45 AM - Review of the Facility Assessment, which was dated May 2024, revealed on page 5 Infection Preventionist: [E3] (ADON).
6/27/24 1:56 PM - During an interview, E4 (Clinical Specialist) stated, That's not right. [E2] (DON) is the facility Infection Preventionist. [E3] cannot be the Infection preventionist; she is not certified.
7/1/24 10:46 AM - During an interview, E4(Clinical specialist) stated, Infection control is a group effort while we try to fill the role. We had someone and then at the last minute, they turned down the role. [E2] (DON), [E3] (ADON) and [E33] (RN/MDS Coordinator) work on it together.
The facility provided proof of E33's training and certification for the role of Infection Preventionist.
Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON), E3 (ADON), E4 (Clinical Specialist) and two State of DE Ombudsmen (via telephone).
Jan 2024
10 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0660
(Tag F0660)
Someone could have died · This affected 1 resident
Based on record review and interviews, it was determined that for one (R6) out of three residents reviewed for discharge, the facility failed to develop and implement an effective discharge planning p...
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Based on record review and interviews, it was determined that for one (R6) out of three residents reviewed for discharge, the facility failed to develop and implement an effective discharge planning process. The facility failed to determine and document the feasibility of R6 returning to live in the community independently. The facility failed to ensure R6's health and safety needs were able to be met at her discharge destination. The facility failed to ensure R6 had the ability to fill her medication prescriptions. The facility failed to ensure that R6's discharge prescriptions for PT/OT, home health aide and nursing were referred to an accepting agency and the first visit by the agency was scheduled for R6. These failures placed R6 in Immediate Jeopardy (IJ). An IJ was called on 1/5/24 at 2:49 PM. The IJ was abated on 1/8/23 at 12:46 PM. Findings include:
The facility's policy stated, Discharge Summary and Plan: Policy Statement- When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment .If a resident indicates interest in returning to the community, he or she will be referred to local agencies and support services that can assist in accommodating the resident's post discharge preferences .A member of the IDT (interdisciplinary team) will review the final post-discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place. 2001 MEDPASS (Revised December 2016).
Cross refer F622, F644 and F745
Review of R6's clinical record revealed:
11/3/23 - R6 was admitted to the facility with diagnoses including, but were not limited to morbid obesity, right elbow bursitis, weakness, COPD (chronic obstructive pulmonary disease) and major depressive disorder.
11/30/23 2:38 PM - E11 (LSW) documented in a Social Services Note in R6's EMAR, .Resident (R6) was requesting to speak to SW (social work) .I introduced myself and stated who I was as this was my first time meeting the resident. Resident stated that she needed my help with discharge plans because her managed care plan as (sic) issued her a discharge notice and she is scheduled for discharge on Saturday, 12/2/23. Resident asked if I could order her a bariatric wheelchair and set up transportation through [transport company] to get her a ride home. SW asked her what time she wanted to discharge, and she stated 11 AM would be ideal. Resident did ask how much the daily rate was to stay privately. SW (social worker) informed her the daily rate was $367 a day and resident stated she does not have the money and she will choose to go home and was in agreement with discharging .A call was placed to resident's son [F1] to inform him of his mother's discharge. F1 stated he understood the process and would go see the resident at home over the weekend to help her fill out the LTC (long term care) Medicaid application. The son never stated any additional information in regard to money, resident staying paying privately or refusing to accept the fact that the resident was discharging.
12/1/23 - E7 (MD) entered an order in R6's EMAR that stated, Discharge Home: D/C (discharge) resident from skilled services PT/OT/ST to home/ALF (assisted living facility) on 12/2/23 with Home Health services, RN eval (evaluation), PT, OT HHA (home health aide).
R6's discharge destination was an apartment in an independent living community, where R6 lived alone.
12/2/23 10:59 AM - E8 (RN) electronically signed R6's Transition of Care and Discharge Summary. R6's Discharge Summary documented, .Skin review .open area to LLQ (left lower quadrant)[abdomen]. Dressing completed this am . Skin issue type- incontinent associated dermatitis. Bowel and Bladder- Bowel continence- occasionally incontinent. Urinary incontinence- occasionally incontinent .Nursing Summary of Stay- .Resident is continent of bowel and bladder with use of bedpan. Resident is a Hoyer transfer .
E9 (OTR) documented in R6's Transition of care and discharge Summary, .Therapy Assistance recommended- Transfers- substantial maximal assistance .Bathroom activity- substantial maximal assistance .Personal hygiene- substantial maximal assistance . Walking- dependent .Ability to move from one location to another- dependent .Bathing- substantial maximal assistance. Therapy summary of stay- .Patient with limited out of bed activity. Recommend 24 hour care at the time of discharge.
The facility was unable to provide evidence that R6 was capable of transferring herself from the bed to the chair or to the commode or that R6 was capable of performing personal hygiene after toileting at the time of discharge.
12/2/23 10:59 AM - R6's Discharge Summary did not include any information regarding the transition of R6's care to a provider in the community. In fact, the Discharge summary read, Follow up with primary care physician: _______________________________.
There was no information provided regarding R6's follow up care with a primary care physician.
12/2/23 11:00 AM - R6 was discharged home via stretcher in a [transport company] ambulance.
R6 was given a paper prescription for community services that stated, PT, OT, RN and HHA (home health aide) 3X (times)/wk (week) X 1 month.
The facility could not provide evidence that the prescription referrals for outpatient physical therapy (PT), occupational therapy (OT), and registered nurse and home health aide visits from a home health agency had been sent to and accepted by a home health agency. Nor could the facility provide evidence that the first visit for each outpatient service was set up and that information was communicated to R6.
R6 was also given paper prescriptions for the eleven medications that she was continue at home. These medications included: Norvasc (blood pressure medication) 10 mg daily, metoprolol (blood pressure medication) 25 mg twice a day, Eliquis (blood thinner for Afib) 5 mg twice a day, Flovent inhaler 100 mcg inhaled twice a day for COPD, lisinopril (blood pressure medication) 30 mg daily, Wellbutrin (depression medication) XL 150 mg daily and Wellbutrin (depression medication) XL 75 mg daily.
The facility could not provide any documentation that the medication prescriptions were called into a pharmacy or that arrangements were in place for R6 to fill the prescriptions and obtain her medications.
From 12/2/23 (Saturday) at 11 AM until 12/4/23 (Monday) at approximately 7 AM, R6 was alone in her apartment without healthcare services.
12/4/23 7:20 AM - E12 (Emergency Department MD) documented in the ED (Emergency Department) Physician Record, . History of Present Illness .Says she [R6] lives at home, has no assistance at this time .They [the facility] reportedly were going to work on home health care but she (R6) said there (sic) been none there (sic). She [R6] is unable to ambulate at home, is incontinent of urine at baseline and has been unable to care for herself .Assessment & Plan: . She [R6] comes with no real new complaints .Her physical exam is unremarkable .
12/7/23 1:51 PM - E13 (ED DO) documented in ED Physician Record Addendum, . Nurse manager has been working with several hospital administrators and case management to help facilitate disposition as pt (patient) has been here in the ED for over 3 days . was able to secure a bed at a facility (in New Jersey), specifics are still in process.
12/8/23 3:16 PM - R6 was discharged from the hospital Emergency Department and transferred to a facility in New Jersey.
R6 spent four days in the hospital Emergency Department while awaiting placement in long term care facility.
1/3/23 1:13 PM - During an interview, E9 (OTR) stated, .therapy recommended a hoyer lift with 24 hours care. Business office manager [E10] went over the Medicaid application process. So going into that weekend, I [E9] thought she [R6] was staying. I was there when she signed the NOMNC (notification of medical non-coverage) and the SNF ABN. I thought she was staying. The family said they would be in to fill out the Medicaid paperwork. Not sure what happened - you would need to ask the Business office. With regard to R6's therapy sessions, she [R6] got out to the wheelchair using a hoyer lift a couple of times. She [R6] had some straight out refusals (to get out of bed for therapy), some 'can we do stuff in bed?' Despite education about trying to get to a level of function where she [R6] could go home and be safe, she [R6] was minimal at participating. When R6 was asked about how she planned to function at home alone, E9 stated, she [R6] said I can't go home like this. I'll figure it out. E9 stated that she [R6] requested that therapy order a bariatric wheelchair but could not order a hoyer as someone has to be there on delivery to get training and R6 lived alone. When asked if AMA (against medical advice) ever came up, E9 stated, not that I remember.
1/4/24 10:26 AM - During an interview, E11 (Social Worker) stated, First time I met her [R6] was on 11/30/23 (Thursday), she [R6] said I need you [E11] to arrange transport with [transport company] at 11 am on Saturday (12/2/23) and a bariatric wheelchair. E9 in Therapy arranged for the bariatric wheelchair through [business name] (an application to order durable medical equipment) as I don't have access .
When E11 was asked about community referrals, E11 stated, I did not fax any referrals. I arranged for the transport home that she [R6] requested. That was it.
1/4/24 2:43 PM - During an interview, E3 (Clinical Specialist) stated, Not having a social worker really caught us out .
1/5/24 1:56 PM - During a telephone interview, F1 (R6's son) stated, She [R6] called 911 to take her to the hospital. She could not walk or get out of bed. One neighbor helped her with food and water. She was incontinent the whole time in the same diaper that she left the facility in.
1/5/24 2:49 PM - The facility was notified of an Immediate Jeopardy (IJ) with respect to R6's discharge.
1/5/24 5:22 PM - The abatement plan for this IJ was accepted by the State Agency. This abatement plan included: -review of the Discharge Summary and Plan policy, education of 100% of Nursing and Administrative staff regarding the discharge planning process, audits of all current residents and all discharges in the last 30 days to ensure appropriate discharge planning is in placed or occurred, contacting all residents discharged in the last 30 days to ensure all care service referrals were completed, the creation of a Discharge Planning process checklist, the initiation and completion of the Discharge Assessment within 72 hours of admission, the coordination of post-discharge follow up appointments by the facility, scheduled calls to discharged residents to monitor their success in the community, and IDT (interdisciplinary team) review of all discharges.
1/8/24 12:30 PM - Findings were reviewed with E1 (NHA), E2 (ADON), E3 (Clinical specialist), E4 (acting ADON) and E14 (DON).
1/8/24 12:46 PM - The facility alleged that the abatement was completed. The abatement was confirmed by reviewing the staff education sign in sheets, interviewing nurse staff regarding discharge education, reviewing audit sheets of last 30 day discharges, reviewing the Discharge Planning Process checklist and reviewing the scheduled IDT discharge review appointments.
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
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
Based on record review and interviews, it was determined that for one (R6) out of three residents reviewed for discharge, the facility failed to allow R6, who still required the nursing services provi...
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Based on record review and interviews, it was determined that for one (R6) out of three residents reviewed for discharge, the facility failed to allow R6, who still required the nursing services provided by the facility, to remain in the facility and to assist R6 with the Medicaid coverage application. Findings include:
Review of R6's clinical record revealed:
11/3/23 - R6 was admitted to the facility with diagnoses including but not limited to morbid obesity, right elbow bursitis, weakness and major depressive disorder.
12/1/23 - E7 (MD) entered an order in R6's EMAR that stated, Discharge Home: D/C (discharge) resident from skilled services PT/ OT/ST to home/ ALF (assisted living facility) on 12/2/23 with Home Health services, RN eval, PT, OT HHA (home health aide).
12/2/23 10:59 AM - E8 (RN) electronically signed R6's Transition of Care and Discharge Summary. R6's Discharge Summary stated, .Bowel and Bladder- Bowel continence- occasionally incontinent. Urinary incontinence- occasionally incontinent .Nursing Summary of Stay- .Resident is continent of bowel and bladder with use of bedpan. Resident is a Hoyer transfer .
E9 (OTR) documented in R6's Transition of care and discharge Summary, .Therapy Assistance recommended- Transfers- substantial maximal assistance .Bathroom activity- substantial maximal assistance .Personal hygiene- substantial maximal assistance .Ability to move from one location to another- dependent .Bathing- substantial maximal assistance. Therapy summary of stay- .Patient with limited out of bed activity. Recommend 24 hour care at the time of discharge.
12/2/23 11:00 AM - R6 discharged home via stretcher in an ambulance. R6's discharge destination was an apartment in an independent living community, where R6 lived alone.
1/3/24 2:10 PM - During an interview with E2 (DON) and E4 (acting ADON), E4 stated, We should have done AMA if we knew she was leaving. We thought she was staying and filling out Medicaid paperwork.
1/3/24 2:42 PM - During an interview, E10 (Business Office Manager) stated that she spoke with F1 (R6's son) on the phone on Wed 11/29/23 at 2:30 PM. E10 stated, I sent the Medicaid application and an informational packet via email on 11/29 at 2:58 PM. The son [F1] was going to call me with a time that he [F1] would come in and fill out the Medicaid application. I re-sent the email on Sunday 12/3/23 because the email bounced back due to the wrong email address. E10 stated that discharging AMA was never discussed as I [E10] thought she [R6] was staying and completing the Medicaid application. Sometime after 4 pm Friday 12/1 and Saturday 12/2, she [R6] decided to discharge and left the facility. E10 also stated, Looking at her data, it is likely that she [R6] would have qualified for Medicaid coverage.
1/3/24 3:23 PM- During an interview, E4 (acting ADON) stated, We were all operating under the idea that she [R6] was staying and filling out the Medicaid application. Then the following week (after R6 had discharged on 12/2/23), we [E4, E2] saw the social work note dated 11/30/23 2:38 PM stating 'she [R6] is scheduled to discharge on Saturday 12/2/23 . set up transportation through [transport company] to get her a ride home'. This information (that transportation home was set up for R6 on Saturday 12/2/23) was not communicated to us [E2, E4].
1/8/24 12:30 PM - Findings were reviewed with E1 (NHA), E2 (ADON), E3 (Clinical specialist), E4 (acting ADON) and E14 (DON) at the exit conference.
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
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that for one (R15) out of three residents reviewed for hospitalization, ...
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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 (R15) out of three residents reviewed for hospitalization, the facility failed to notify the LTC Ombudsman of R15's transfer and admission to the hospital on [DATE]. Findings include:
6/28/23 - R15 was admitted to the facility with diagnoses including but not limited to stroke and diabetes.
9/29/23 - A quarterly Minimum Data Set (MDS) assessment documented R15's Basic Inventory of Mental Status (BIMS) as 15, which was reflective of normal cognition.
10/23/23 - R15 admitted to [hospital] with osteomyelitis and underwent a right fifth toe amputation.
1/5/24 10:15 AM - During an interview, E4 (ADON) stated that she looked at the month of October Ombudsman notification sheet and R4 was not on the list.
1/8/24 12:30 PM - Findings were reviewed with E1 (NHA), E2 (ADON), E3 (Clinical specialist), E4 (acting ADON) and E14 (DON) at the exit conference.
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 F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined that for one (R10) out of four residents reviewed for Hospice care, the facility failed to complete an MDS assessment documenting R10's signific...
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Based on record review and interview, it was determined that for one (R10) out of four residents reviewed for Hospice care, the facility failed to complete an MDS assessment documenting R10's significant change regarding his hospice admission. Findings include:
6/15/23 - R10 was admitted to the facility with diagnoses including, but were not limited to, stroke, seizures and congestive heart failure (CHF).
12/8/23 - R10 was admitted to hospice services at the facility.
1/5/24 - The Surveyor observed that R10's significant change Minimum Data Set (MDS) assessment was noted as in progress. This was twenty-eight (28) days after his admission to hospice and fourteen (14) days after R10's deadline for completion of the significant change MDS assessment.
1/5/24 1:35 PM - During an interview, E3 (Clinical Specialist) confirmed that R10's significant change MDS assessment's status was still in progress.
1/8/24 9:20 AM - E22 (admission coordinator) delivered a copy of R10's completed significant change MDS (dated 12/14/23) to this Surveyor.
1/8/24 12:30 PM - Findings were reviewed with E1 (NHA), E2 (ADON), E3 (Clinical Specialist), E4 (acting ADON) and E14 (DON) at the exit conference
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
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
Based on record review and interviews, it was determined that for one (R6) out of three residents reviewed for Preadmission Screening and Resident Review (PASARR) coordination, the facility failed to ...
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Based on record review and interviews, it was determined that for one (R6) out of three residents reviewed for Preadmission Screening and Resident Review (PASARR) coordination, the facility failed to be compliant with R6's PASARR mandated specialized services of a one-time psychiatric medication management evaluation by a psychiatrist/psychiatric nurse practitioner within 30 days of admission. Findings include:
Review of R6's clinical record revealed:
11/1/23 - R6's PASARR determination at the hospital documented R6's medical history as including two suicide attempts by overdosing on her medications on 9/24/23 and 9/25/23 with hospitalization on 9/26/23, hospitalization 10/10/23- 10/27/23 for kidney stones, and rehospitalization on 10/28/23 after one day at home due to a fall.
PASARR determination explanation stated, .You have a Level II PASARR condition of Major Depressive Disorder, recurrent, severe, without psychosis which has recently led to functional impact and need for ongoing treatment support. If you are admitted to a Medicaid certified nursing facility .you will need to be provided the following specialized services: Psychiatric Provider Evaluation within 30 days of admission. A one-time psychiatric medication management evaluation by a psychiatrist/psychiatrist nurse practitioner/medical doctor (to evaluate response and effectiveness of psychotropic medications .) .To be compliant, this service must be delivered within 30 days of the resident admitting or re-admitting from a hospitalization to the nursing facility.
11/3/23 - R6 was admitted to the facility with diagnoses including, but were not limited to, morbid obesity, right elbow bursitis, weakness and major depressive disorder.
11/3/23 - E7 (DO) ordered, May have psych consult and treatment in R6's EMAR (electronic medical record).
11/5/23 - E7 (DO) gave a verbal order for, bupropion HCL ER (XL) 150 mg (milligrams)- give one tablet by mouth in the morning related to depression.
11/21/23 - E7 (DO) entered an order in R6's EMAR for, bupropion HCL 75 mg- give one tablet by mouth in the morning for depression.
12/1/23 - E7 (DO) entered an order in R6's EMAR that stated, Discharge Home: D/C (discontinue) resident from skilled services PT/ OT/ST to home/ ALF (assisted living facility) on 12/2/23 with Home Health services, RN eval, PT, OT, HHA (home health aide).
12/2/23 11:00 AM - R6 was discharged home via stretcher by a [transport company] ambulance.
1/4/23 11:35 AM- During an interview, E4 (acting ADON) stated, No, I did not find any psych (psychiatry) notes for R6. I called the Psych NP (E6) to see if she has any. We [the facility] did have GDR (gradual dose reduction) meeting on 12/13/23 but she (R6) was gone (discharged ) by then.
1/5/23 10:35 AM - During an interview, E4 (acting ADON) stated that if a resident is determined to need a psych (psychiatry) consult, their name and room number is written in a E5's (psychiatrist) book at the nurse's station. When E5 comes to the facility, he [E5] checks the book and sees the residents listed. E4 (acting ADON) reported there was no record of R6's name in the Psych book at the nurses' station.
1/5/23 10:54 AM - Electronic message (text) from E5 (Psychiatrist) stated, I tried to call you back. I don't see patients but my NP [E6] goes there. When I went to do GDR, patient [R6] was already discharged . So I am sorry I don't know the patients (sic).
1/5/23 4:43 PM - During a telephone interview, E6 (E5's Psych NP) stated, I checked my billing records. I did not see R6 listed so I did not see her.
Both E5 (Psychiatrist) and E6 (Psych NP) confirmed that they did not have any encounters with R6 nor evaluated her medications' effectiveness as required by R6's PASARR.
1/8/24 12:30 PM - Findings were reviewed with E1 (NHA), E2 (ADON), E3 (Clinical specialist), E4 (acting ADON) and E14 (DON) at the exit conference.
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
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, it was determined that for four (R3, R9, R19 and R21) out of six residents ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, it was determined that for four (R3, R9, R19 and R21) out of six residents reviewed for respiratory care, the facility failed to provide respiratory care consistent with professional standards. R3 was sent to an outpatient appointment without enough supplemental oxygen to last for the duration of the excursion. R9, R19 and R21 all had oxygen compressors with dusty/dirty filters. R21's oxygen tubing was not changed as ordered. Findings include:
1.
Review of R3's clinical record revealed:
4/24/23 - R3 was admitted to the facility with diagnoses including, but were not limited to, COPD, congestive heart failure (CHF) and respiratory failure with hypoxia.
4/24/23 - E7 (DO) placed an order in R3's EMAR stating, Continuous Oxygen @4 liters/min (minute) via nasal cannula to maintain pulse ox above 92% every shift. E7 (DO) also placed another order stating, Change O2 tubing and humidifier bottle every Monday 11-7 (shift). Date, time, and initial tubing (as a nursing measure) every night shift every Mon.
4/24/23 - E7 (DO) wrote an order in R3's chart stating, Cardiology appointment with MD [E18] on 5/1/23 at 1:15 PM. [Cardiology office address] [NAME] DE 19713.
4/25/23 - E7 (DO) gave a verbal order regarding R3 stating, Pulse ox, lung assessment, full vitals and assessment progress note every shift for SOB (shortness of breath) monitoring.
4/28/23 - The admission Minimum Data Set (MDS) evaluation documented R3's Basic Inventory of Mental Status (BIMS) score as 13, which was reflective of normal cognition.
5/1/23 - R3 was transported to [Cardiology office] by the facility's bus wearing supplemental oxygen being delivered by a portable tank.
5/1/23 4:17 PM - E4 (acting ADON) documented in a general note .[R3] at the [Cardiology office] and was transported by the facility's bus. Received call from the [Cardiology] office at about 1:28 PM stating the resident [R3] was done and that the driver stated that he was not in the area. Educated her [Cardiology office staff member] the driver had other residents to drop off and will be picking her [R3] up. The [Cardiology] office stated someone was supposed to accompany resident according to their office policy but that was not (sic) communicated to the (facility) scheduler when she called to confirm the appointment. Received another call from the [Cardiology] office at about 2:50 PM stating the driver had arrived to pick the resident [R3] up and the resident's oxygen was out . I [E4 acting ADON] took oxygen to the office .F2 (R3's grandson) stated he [F2] wanted to take her [R3] home and the nurse [E19] at the doctor's office suggested resident [R3] be taken to the ER so social services could get involved and set up home care. Apologized to grandson [F2] about everything and resident [R3] was taken to [NAME] ER.
The facility failed to assure that R3 had enough portable supply of oxygen to last the duration of her excursion to her Cardiologist's office.
5/1/23 - R3 was admitted to the hospital with diagnosis of gastrointestinal bleed.
1/2/23 2:50 PM - During a telephone interview, E19 (RN Nurse manager Cardiology office) read from her notes regarding the incident with R3 on 5/1/23, . [R3] from [facility] unattended without oxygen for 4 hours. She [R3] had an accident and had to be cleaned up. Called facility multiple times. Was admitted [to the hospital] for GI bleed. Was on supplemental oxygen.
1/2/24 3:19 PM - This surveyor received an email from E19 (RN Cardiology Nurse manager), which stated, I did review [R3's] chart with my MA (medical assistant) manager and she also cannot confidently state that she came here without oxygen (replacement tank).
2.
Review of R9's clinical record revealed:
11/9/17 - R9 was admitted to the facility with diagnoses including, but were not limited to, pulmonary fibrosis, chronic obstructive pulmonary disease (COPD), dementia and CHF.
11/22/22 - E7 wrote an order in R9's EMAR (electronic medical record) stating, O2 (oxygen) via NC (nasal cannula) PRN (as needed) SOB (shortness of breath) or pulse ox (oximetry) < (less than) 92%.
1/3/24 9:52 AM - This Surveyor observed R9's supplemental oxygen compressor with a filter that was loaded with dust. This observation was confirmed by E17 (RN).
3.
Review of R19's clinical record revealed:
5/17/19 - R19 was admitted to the facility with diagnoses including, but were not limited to, COPD, CHF and obstructive sleep apnea (OSA).
11/15/23 - E7 placed an order in R19's EMAR stating, O2 2 L (liters)/min via nasal cannula continuous every shift related to COPD.
11/16/23 - E7 ordered, Change and date O2 tubing and humidifier bottle every night shift every Monday in R19's EMAR.
1/3/24 9:57 AM - This Surveyor observed R19's supplemental oxygen compressor with a dirty and dusty filter. The oxygen tubing was not dated, but the humidifier water bottle was dated 1/2/24. R19 stated to the Surveyor, Sometimes I clean it (the compressor filter) myself. These observations were confirmed by E17 (RN).
4.
Review of R21's clinical record revealed:
1/28/22 - R21 was admitted to the facility with diagnoses including, but were not limited to, COPD, CHF and end stage renal disease with dependence on renal dialysis.
4/8/23 - E7 (DO) placed an order in R21's EMAR stating, Oxygen 2 Liter/min via NC to maintain pulse ox (oximetry) > (greater than) 92% as needed for SOB (shortness of breath)/wheezing.
11/16/23 - E7 (DO) placed an order in R21's EMAR stating, Change mask/cannula and tubing, water for humidification as needed and every night shift every Monday.
1/3/24 9:47 AM - This Surveyor observed R21's supplemental oxygen compressor with a dirty and dusty filter and the oxygen tubing attached to the compressor was dated 12/19/23. These observations were confirmed by E17 (RN).
1/8/24 12:30 PM - Findings were reviewed with E1 (NHA), E2 (ADON), E3 (Clinical specialist), E4 (acting ADON) and E14 (DON) at the exit conference.
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 F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, it was determined that for one (R5) out of four residents reviewed for Hospice care, the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, it was determined that for one (R5) out of four residents reviewed for Hospice care, the facility failed to provide pain management consistent with professional standards. R5, who was admitted to the facility on [DATE] on hospice services, did not receive any narcotic pain medication until four days after admission. Findings include:
The facility's Pain Assessment and Management policy stated, the pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standard of practice .Monitor the resident by performing a basic assessment with enough detail and, as needed, with standardized assessment tools (e.g. approved pain scales, etc) . MED-PASS Revised March 2020
The pain management standards were approved by the American Geriatrics Society in April 2002 which included: appropriate assessment and management of pain; assessment in a way that facilitates regular reassessment and follow-up; same quantitative pain assessment scales should be used for initial and follow up assessment; set standards for monitoring and intervention; and collect data to monitor the effectiveness and appropriateness of pain management.
Review of R5's clinical record:
5/14/23 10:58 PM - R5 was admitted to a hospital from another long-term care facility after a fall with a mental status change. During the trauma work up, R5's CT (computed tomography) scan revealed a pancreatic lesion with osteoblastic metastatic disease. R5's pain was managed with Dilaudid 0.3 mg IV push every 4 hrs PRN for pain (Equivalent of 30 mg Morphine) while in the hospital.
5/19/23 - R5 was admitted to the facility with diagnoses, including but were not limited to, multiple sclerosis, dementia and pancreatic lesion with osteoblastic (bone) metastatic disease.
5/19/23 4:49 PM - E20 (LPN) documented in R5's admission note stating, .Resident denies any pain or discomfort at this time .
5/19/23 - E7 (DO) gave a verbal order, Monitor [R5's] pain level every shift. This order was signed off by the nurses in R5's Medication Administration Record (MAR).
Review of the documentation in R5's MAR for May 2023 regarding Monitor [R5's] pain level every shift revealed twelve different nurses having documented a check during each shift for the dates of 5/19 to 5/26/23.
Nurses' notes from 5/20/23 7:13 AM, 5/20/23 1:57 PM, 5/20/23 11:46 PM, 5/21/23 2:31 AM, 5/21/23 1:27 PM and 5/21/23 11:09 PM documented R5 denies any pain or discomfort.
5/19/23 - E7 (DO) gave a verbal order, Pain rating on a scale of 0-10 (as a nursing measure) every shift for pain. This order was documented on by the staff in R5's Treatment Administration Record (TAR).
Review of the documentation in R5's TAR for May 2023 regarding Pain rating on a scale of 0-10 (as a nursing measure) every shift for pain revealed twelve different nurses having documented a check, rather than the ordered pain scale of 0-10, during each shift for the dates of 5/19 to 5/26/23.
The facility's nurses failed to quantify with a number R5's pain as ordered using a scale of 0-10 (numerical rating scale).
5/19/23 - E7 (DO) gave a verbal order, Acetaminophen Oral tablet (Tylenol) -give 650 mg by mouth every 6 hours as needed for mild pain 1-3. The administration of this medication was to be documented in R5's MAR.
Review of R5's MAR revealed only one dose of Tylenol 650 mg was given during R5's stay at the facility.
5/20/23 5:53 PM - E23's (NP) progress note documented, History of present illness: .Patient (R5) was also on Dilaudid in the hospital secondary to continued complaints of back pain with tachycardia. Unfortunately was also noted with osteoblastic metastatic disease and pancreatic disease .Patient denies any pain although aide states patient had just stated that his back was bothering him .Niece [F4] would like to continue with hospice care and would like patient's pain addressed .Assessment & Plan: . Back Pain- patient with complaints of back pain, history of the same, was previously on Dilaudid in the hospital and morphine prior to that, will restart morphine routine and as needed, did discuss with patient's niece [F4] . will reach out to hospice regarding niece's concerns .
Despite documenting that morphine pain medication was to be started, no order for narcotic pain medication was ordered.
5/22/23 12:32 - R5 was administered Tylenol 650 mg by mouth for abdominal pain, which was documented as effective' in the follow up note at 2:36 PM. The facility could not provide any evidence of documentation of R5's pre- or post-pain scale with regarding to the administration of this pain medication.
5/22/23- Two days later, E23 (NP) ordered Morphine solution 20 mg/5 ml- give 0.25 ml (5 mg) PO (per mouth) every 4 hours PRN (as needed) for pain/SOB (shortness of breath) and give 0.25 ml (5 mg) two times a day for pain.
This order scheduled R5 to receive morphine sulfate solution 20 mg/1 ml 0.25 ml (5 mg dose) at 9 AM and 9 PM with an order for breakthrough pain of 0.25 ml (5 mg dose) every 4 hours as needed.
Duing an interview on 1/2/24, F4 (R5's niece) stated that due to concerns with care, R5's hospice care was transferred to another hospice agency. This was confirmed by E4 (acting ADON).
5/22/23 5:49 PM - C1 (RN) documented in R5's hospice care consultant initiation visit, .complains of pain all the time, only has Tylenol ordered .This month after a fall, found malignant cancer .
5/23/23 2:12 PM - E7's (DO) admission History & Physical (H&P) for R5 documented, .imaging also did reveal bony mets (metastasis) from the cancer . Hospice is seen (sic) patient, is requesting comfort medications to be started and initiated for patient, he is alert, confused , unable to answer questions appropriately . Assessment & Plan: Adult failure to thrive- .he is on hospice care, we will add morphine (pain medicine), Ativan (anxiety medicine), levsin (medication used to manage excessive oral secretions in dying patients) for patient comfort .
This Surveyor obtained a copy of the [pharmacy] manifest documenting the first delivery of morphine sulfate 20 mg/1 ml solution as delivered to the facility on 5/23/23 at 3:36 AM.
5/23/23 9:00 AM- R5 received his first documented dose of morphine sulfate solution (narcotic pain medication) 1 mg by mouth, four days after admission to the facility.
5/24/23 - An admission Minimum Data Set (MDS) assessment documented R5's Basic Inventory of Mental status (BIMS) as three, which was reflective of severe cognition deficit.
5/25/23 - E7 (DO) ordered an increase in R5's pain medication to Morphine solution 20 mg/1 ml- give 5 mg PO (by mouth) every 4 hours as needed pain/SOB and give 5 mg PO every 8 hours for pain/SOB.
This new order scheduled R5 to receive morphine sulfate solution 20 mg/1 ml 0.25 ml (5 mg dose) at 6 AM, 2 PM and 10 PM with an order for breakthrough pain of 0.25 ml (5 mg dose) every 4 hours as needed.
1/2/24 10:39 AM - During an interview, F4 (R5's niece) stated that she was not happy with {business name] hospice when R5 was admitted to the facility from the hospital so she opted to change to a different hospice provider within the first days of R5's stay at this facility.
1/4/24 11:02 AM - During an interview, E4 (acting ADON) stated, admission orders are written by the provider and then the unit clerk takes them off. If an order is written to monitor pain, unless the provider writes to mark the level reported, the order may not have a spot to document the level of pain that the resident reports. The check just documents that it was done.
1/8/24 12:30 PM - Findings were reviewed with E1 (NHA), E2 (ADON), E3 (Clinical specialist), E4 (acting ADON) and E14 (DON) at the exit conference.
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 F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
Based on record review and interviews, it was determined that for one (R6) out of three residents reviewed for discharges, the facility failed to identify and provide R6 medically-related social servi...
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Based on record review and interviews, it was determined that for one (R6) out of three residents reviewed for discharges, the facility failed to identify and provide R6 medically-related social services to maintain her highest practicable physical, mental and psychosocial well-being. Findings include:
Cross refer F625, example # 1, F644, and F660
Review of R6's clinical record revealed:
11/1/23 - R6's PASARR evaluation was completed prior to her admission to the nursing facility, which documented that R6 required the following specialized services within 30 days of admission:
- an evaluation by a psychiatric Provider within 30 days of admission; and
- a one-time psychiatric medication management evaluation by a Provider.
R6's PASARR also documented that the following services and/or supports would need to be provided:
- case management to explore community based living, family involvement or training in R6's care;
- ongoing evaluations of the effectiveness of current psychotropic medications on target symptoms and a safety plan; and
- if R6 returned to the community, the resident may need: 24-hour care and a safe place to live, someone to physically help you with mobility, assistance with your activities of daily living and care, and continued physical therapy/occupational therapy services.
11/3/23 - R6 was admitted to the facility with diagnoses including, but were not limited to morbid obesity, right elbow bursitis, weakness and major depressive disorder.
11/9/23 - An admission Minimum Data Set (MDS) documented R6's cognitive status as having a BIMS (Basic Inventory of Mental Status) score of 15, which is reflective of normal cognition.
11/30/23 2:38 PM - E11 (LSW) documented in a Social Services Note in R6's EMAR, .Resident [R6] was requesting to speak to SW (social work) .I introduced myself and stated who I was as this was my first time meeting the resident.
R6 had been in the facility 27 days at the time of her first encounter with a social worker. The facility was not able to provide evidence of any other facility employee who provided medically related social services such as referrals to community based case management, psychotropic medication evaluations, discharge safety plan with regard to R6.
12/2/23 11:00 AM - R6 was discharged home via stretcher by a [transport company] ambulance.
1/3/24 3:23 PM- During an interview, E4 (acting ADON) stated, We did not have a full-time social worker. E11, the Social Worker from [another facility], came in 2 days a week to cover the facility. I am not sure which days E11 comes to our building.
1/4/24 10:26 AM - During an interview, E11 (Social Worker) stated, First time I met her [R6] was on 11/30/23 (Thursday), she [R6] said I need you [E11] to arrange transport with [transport company] at 11 am on Saturday (12/2/23) and bariatric wheelchair. E11 stated, My other building does not do Medicaid pending. So that was not on my radar. I did not even know she had a PASARR II.
When E11 was asked about community referrals, E11 stated, I did not fax any referrals. I arranged for the transport home that she [R6] requested. That was it.
The facility failed to educate R6 of her option to apply for Medicaid and stay in a LTC setting with a Medicaid pending status. The facility failed to provide evidence of referrals for needed community services upon transition from the facility.
1/4/24 11:35 AM- During an interview, E4 (acting ADON) stated, No, I did not find any psych notes for R6. I called the Psych NP [E6] to see if she has any. We did have GDR (gradual drug reduction) meeting on 12/13/23 but she [R6] was gone (discharged ) by then.
1/4/24 2:43 PM - During an interview, E3 (Clinical Specialist) stated, Not having a social worker really caught us out .
1/5/24 10:54 AM - Electronic message (text) from E5 (Psychiatrist) stated, I tried to call you back. I don't see patients but my NP [E6] goes there. When I went to do GDR, patient [R6] was already discharged . So I am sorry I don't know the patients (sic).
1/5/24 4:43 PM -During a telephone interview, E6 (E5's Psych NP) stated, I checked my billing records. I did not see R6 listed so I did not see her [R6].
Both E5 (Psychiatrist) and E6 (Psych NP) confirmed that they did not have any encounters with R6 not evaluated her medications' effectiveness as required by R6's PASARR. The facility failed to arrange and provide PASARR required and needed mental health social services during R6's stay.
1/8/24 11:05 AM -During an interview, E3 (Clinical specialist) stated, We were without a social worker for months.
The facility failed to ensure that the medically related services (such as PASARR review, transition of care referrals) typically provided by the social worker were reassigned in the absence of a designated social worker.
1/8/24 12:30 PM - Findings were reviewed with E1 (NHA), E2 (ADON), E3 (Clinical specialist), E4 (acting ADON) and E14 (DON) at the exit conference.
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 F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
Based on observation and interview it was determined that for one (R7) out of three residents reviewed for call lights, the facility failed to ensure a functioning call bell system. Findings include:
...
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Based on observation and interview it was determined that for one (R7) out of three residents reviewed for call lights, the facility failed to ensure a functioning call bell system. Findings include:
10/9/17 - R7 was admitted to the facility with diagnoses including, but not limited to, Down Syndrome, HTN, non-Alzheimer's dementia and depression.
Review of R7's annual and quarterly MDS respectively documented independence for toileting.
1/4/24 at 10:23 AM - The call light in R7's bathroom did not light up when the cord was pulled by this surveyor to check call light functioning. After three separate pulls on the cord, the light still did not come on. It was noted that the cord was wrapped multiple times around the bathroom rail. E15 (CNA) was asked how R7 calls to get help if needed in the bathroom. Per E15, she [R7] would pull the cord. E15 was asked to demonstrate and upon pulling on the cord said, It's not coming on. E15 was then heard contacting maintenance.
1/4/24 at 12:30 PM - E2 (ADON) and E16 (maintenance technician) presented the cord saying, It worked but the cord had been wrapped around the railing which had kept it from working.
1/4/24 at 12:45 PM - E4 (Director of Assisted Living) was interviewed and asked why a cord was wrapped around the rail in the bathroom. Per E4, I guess the cord was too long. After stating to E4 (Director of Assisted Living) that if the resident needed to use the call light it would not have worked, E4 stated, We'll have to in-service the staff.
1/8/24 at 12:30 PM - Findings were reviewed with E1 (NHA), E2 (ADON), E3 (Clinical specialist), E4 (acting ADON) and E14 (DON) at the exit conference.
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 F0625
(Tag F0625)
Could have caused harm · This affected multiple residents
Based on record review and interviews, it was determined that that for three (R1, R4 & R15) out of three residents reviewed for hospitalization, the facility failed to issue bed- hold notice upon thei...
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Based on record review and interviews, it was determined that that for three (R1, R4 & R15) out of three residents reviewed for hospitalization, the facility failed to issue bed- hold notice upon their hospitalizations. Findings include:
1-Review of R1's clinical record revealed:
5/29/23 - R1 was admitted to the facility with diagnoses including, but not limited to, diabetes, heart failure and right foot ulcer.
6/12/23 - An admission Minimum Data Set (MDS) assessment documented R1's BIMS score as 12, which was reflective of moderate cognitive deficit.
6/29/23 11:15 AM - E20 (LPN) documented in a Transfer Out to Hospital note, Resident is being sent to hospital per family request for right foot wound. Resident is alert and oriented x (times) 3 at time of transfer.
The facility was not able to produce evidence of the written bed-hold policy that was/should have been given to R1 or her family member at the time of transfer to the hospital.
2- Review of R4's clinical record revealed:
10/4/23 - R4 was admitted to the facility with diagnoses including, but not limited to, heart failure, systemic lupus and seizures.
10/8/23 - The 5 Day Medicare MDS assessment documented R4's BIMS score as 9, which was reflective of moderate cognitive deficit.
12/12/23 11:30 AM - E20 (agency RN) documented in an order note, Resident with increased SOB (shortness of breath), productive cough and fever 102.1 F. Seen by the provider [E7], order to transfer to hospital given. POA [F3] was made aware. Left with 911 for [hospital] ED (emergency department) with appropriate paperwork at 11:30 AM.
The facility was not able to produce evidence of the written bed-hold policy that was/should have been given to F3 (R4's daughter) at the time of transfer to the hospital.
3- Review of R15's clinical record revealed:
6/28/23 - R15 was admitted to the facility with diagnoses including but not limited to stroke and diabetes.
9/29/23 - A quarterly MDS assessment documented R15's BIMS score as 15, which was reflective of normal cognition.
10/23/23 - R15 admitted to [hospital] with osteomyelitis and underwent a right fifth toe amputation.
The facility was not able to produce evidence of the written bed-hold policy that was/should have been given to R15 at the time of transfer to the hospital.
1/8/24 11:05 AM - During an interview, E3 (Clinical Specialist) stated, We don't have those forms (bed hold upon transfer) for those three residents (R1, R4 and R15). We were without a social worker for months.
1/8/24 12:30 PM - Findings were reviewed with E1 (NHA), E2 (ADON), E3 (Clinical specialist), E4 (acting ADON) and E14 (DON) at the exit conference.
Apr 2023
2 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 F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of clinical records and other documentation as indicated, it was determined that for two (R1 and R4)...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of clinical records and other documentation as indicated, it was determined that for two (R1 and R4) out of three residents reviewed for advance directives, the facility failed to complete the resident/responsible parties desired advanced directive. Findings include:
which is required for the portable medical order to be valid (Title 16 Health and Safety, regulatory Provisions Concerning Public Health Chapter 25A Delaware Medical Orders for Scope of Treatment). Findings include:
1. R1's medical record revealed:
[DATE]- A verbal telephone order signed by E11 (MD) stated, Resident is capable of understanding his/her rights.
[DATE]- R1 was admitted to the facility with diagnoses including moderate dementia.
[DATE]- A CPR-FULL code order was initiated by E11.
[DATE]- A CPR-FULL code order was discontinued by E11. A Do NOT Resuscitate- DNR/Do Not Hospitalize/Comfort Care/ Do Not weigh order was entered by E11.
[DATE]- The quarterly MDS assessment documented R1's BIMS score as 10 (moderate cognitive impairment).
[DATE] 7:03 PM- E12's Encounter note in the medical record documented that R1 was alert and oriented times two (alert to person and place or time, but not to both).
[DATE]- A verbal order was signed by E11 stating that R1 was admitted under hospice care.
[DATE] - E2 (DON) and E3 (ADON, also covering for the Social Worker) obtained phone consent to complete the DMOST (Delaware Medical Orders For Scope Of Treatment) for a Do Not resuscitate/DNAR order from F1, R1's daughter. The form was not signed by R1 which violates Delaware State Code Title 16, Chapter 25A, 2509A(2)- has been voluntarily signed by the patient or by another individual subscribing the patient's name in the patient's presence and at the patient's express direction, or, if the patient does not have decision-making capacity, by the patient's authorized representative.
[DATE]- The DMOST form was signed by E12 (NP) stating that R1 requested a Do Not Resuscitate/DNAR order. DMOST form Section E Orders Discussed with was not completed on the form nor was there an Encounter note from E12 in the medical record on or around the date of [DATE] specifying who the code status was discussed with from R1's family.
[DATE]- The quarterly MDS assessment documented R1's BIMS score as 9 (moderate impairment).
[DATE]- A Do NOT Resuscitate- DNR/Do Not Hospitalize/Comfort Care/ Do Not weigh order was entered by E11 (MD).
[DATE]- A verbal order signed by E11 stated, Resident is capable of understanding his/her rights.
Although the facility had a DNR documented for R1, the incomplete DMOST would not be honored outside of the facility. The facility failed to follow the advance directive as requested by the resident/responsible party.
2. Review of R4's medical record revealed:
[DATE]- Durable Power of Attorney Paperwork assigning F2 as R4's Power of Attorney was completed.
[DATE]- A verbal order signed by E11 (MD) stated that R4 was not capable of understanding his/her rights.
[DATE]- A Do Not Resuscitate order was entered into the medical record by E11.
[DATE]- E12 completed a portable DMOST form stating that R4 requested a Do Not Resuscitate/DNAR order. DMOST form Section E Orders Discussed with was completed on the form stating that a discussion was held with F2, however, neither R4 nor F2 signed anywhere on the form. There were two Nurse witnesses (unable to read signatures) who signed in Section E. This violates the Delaware State Code Title 16, Chapter 25A, 2509A (2)- has been voluntarily signed by the patient or by another individual subscribing the patient's name in the patient's presence and at the patient's express direction, or, if the patient does not have decision-making capacity, by the patient's authorized representative.
[DATE] at 2:00 PM - Findings were reviewed during the Exit Conference with E1 (Interim ED), E2 (DON) and E4 (Clinical Specialist).
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 F0940
(Tag F0940)
Could have caused harm · This affected 1 resident
Based on interviews and review of facility documentation as indicated, it was determined that the facility failed to ensure that an agency RN (E5) working as a Supervisor on the 11:00 PM to 7:00 AM sh...
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Based on interviews and review of facility documentation as indicated, it was determined that the facility failed to ensure that an agency RN (E5) working as a Supervisor on the 11:00 PM to 7:00 AM shift had the proper training by the facility prior to working in that role. Findings include:
Review of the facility's Staff Posting for the following two night shifts (11:00 PM to 7:00 AM) revealed that E5 was the only RN working: 2/25/23 - 2/26/23 and 4/17/23 - 4/18/23.
4/20/23 at 10:30 AM - During an interview, E5 (Agency RN) confirmed that she had been working as a Supervisor on night shift and she had not received any Supervisor training nor was she familiar with the facilities policies and procedures.
4/20/23 at 11:06 AM - During an interview, E2 (DON) confirmed that E5 (Agency RN) did not have any Supervisor training prior to working in that role on night shift. E2 provided the Surveyor with the Agency Orientation white binder entitled, Agency Nurses Policy and Manual Folder, which had an Inservice Sign-In Sheet that lacked evidence of E5's signature that she reviewed the facility's policies and procedures. E2 also added that the Supervisors exchange a Supervisor binder during each shift change.
4/20/23 at 2:00 PM - The finding was reviewed during the Exit Conference with E1 (Interim ED), E2 (DON) and E4 (Clinical Specialist).
Jan 2023
20 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation and interview, it was determined for one (R15) out of 47 residents reviewed for dignity, the facility failed to protect and value R15's private space when staff entered the reside...
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Based on observation and interview, it was determined for one (R15) out of 47 residents reviewed for dignity, the facility failed to protect and value R15's private space when staff entered the residents room without requesting permission. Findings include:
1/19/23 9:37 AM - During the initial pool interview R15 was asked about any privacy and dignity concerns and R15 stated, Fifty percent of the time when I'm being changed I have to ask them to close the door.
1/20/23 1:43 PM - R15's door was closed with staff present in the room. R15's call light was on.
1/20/23 1:45 PM - E18 (LPN) was observed entering R15's room without knocking and receiving permission to enter. E18 immediately confirmed the finding.
1/26/23 from 1:20 PM to 2:15 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E19 (Regional Clinical Nurse Specialist).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of R8's clinical records revealed the following:
[DATE]- R8 was admitted to the facility.
[DATE] 4:57 PM- An admissi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of R8's clinical records revealed the following:
[DATE]- R8 was admitted to the facility.
[DATE] 4:57 PM- An admission Initial Note by nursing stated that R8 was a DNR (do not resuscitate or perform life saving measures such as CPR), DNI (do not intubate or put in a breathing tube) and DNH (do not hospitalize). COMFORT CARE (keep as comfortable as possible), no tube feeding and no weights. R8 was noted to be confused, but pleasant and easily directed.
[DATE]- A Physician's order was written for AD (advance directive): DNR.
[DATE] and [DATE] Physician notes stated, . Code Status: DNR/DNI/DNH, comfort care, no tube feeds . Advance Care Planning Details: The patients values and overall goals of future treatment/care were discussed. The patient has the following goals to remain a DNR/do not hospitalize comfort care no tube feeds .
[DATE]- R8's MDS assessment revealed that she had severe cognitive impairment.
Record review lacked a copy of advanced directives for R8.
The facility failed to provide R8 or her POA (Power of Attorney) the opportunity to formulate an advance directive and document that it was offered or declined by the resident or her POA.
[DATE] from 1:20 PM to 2:15 PM- Findings were reviewed during the exit conference with E1 (NHA) E2 (DON) and E19 (Regional Clinical Nurse Specialist).
Based on interview and record reviews, it was determined that for two (R8 and R17) out of three residents sampled for advanced directives, the facility failed to offer the opportunity to these residents to formulate an advanced directive and document the discussions in each residents' clinical record. Findings include:
The facility's admission paperwork, under the Advanced Directives section, documented, Residents are permitted and encouraged to have an advance health care directive, and any other related documentation recognized by state law, in their file at the Community. If you have executed any advance directives, you must provide a copy to us upon move-in. If you change your advance directive while a resident of the Community, you must provide us with a copy of the new advanced directive. Information on Advance Health Care Directives is attached here. Attached was a 2 page brochure from the DHSS Long Term Care Ombudsman's Office.
12/2016 (last revised) - The facility's policy entitled Advance Directives stated, . 6. Prior to or upon admission of a resident, the social services director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives . 8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. a. The resident will be given the option to accept or decline the assistance . b. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance . 18. The interdisciplinary team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument (MDS).
1. R17's clinical record revealed:
[DATE]- Review of the quarterly MDS assessment revealed that R17 was independent in making consistent and reasonable decisions.
Review of R17's clinical record lacked evidence that the resident had an advance directive nor was offered and/or declined the opportunity to formulate an advanced directive with the facility's assistance after she was admitted to the facility on [DATE].
[DATE] at 9:02 AM - During an interview, E21 (SW) confirmed the finding.
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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and review of facility documentation, it was determined that for one (R298) out of 14 sampled re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and review of facility documentation, it was determined that for one (R298) out of 14 sampled residents, the facility failed to immediately consult the Physician when R298 experienced a change in condition after an unwitnessed fall. Findings include:
Review of R298's clinical record revealed:
R298 was admitted to the facility on [DATE] with a past medical history including Congestive Heart Failure, Dementia, and a history of falling.
11/7/22 at 12:00 PM- R298 was found lying on the floor face up on her back. The fall was unwitnessed.
11/8/22 at 10:40 AM- A progress note documented, R298 was transferred to the hospital. Resident sustained fall from bed yesterday. Resident noted with bruise to right lower lip chin area and tongue. Oral cavity assessed, no s/s (signs or symptoms) of active bleeding and/or open areas noted. Resident noted with increased confusion and lethargy. Resident opens eyes with verbal and tactile (touch) stimuli for a few seconds. Resident unable to follow commands. Resident noted to not be able to hold her fork while eating breakfast. [R298's Physician was] in facility at time of assessment and made aware of findings. New order received to transfer resident to ER for eval and treat . EMT arrived at facility to transport resident to [NAME] Hosp ER at 1020.
11/14/22- An incident report documented that E29 (Agency RN) was assigned during the 11 PM to 7 AM shift and noted that R298 slept throughout the shift except for when Neurochecks were performed. E29 stated the resident was alert and oriented to self and able to follow simple commands. E29 also noted that during 6 AM Neurochecks, R298 had brown emesis (vomit) on the left side of the bed and the residents' tongue was brown in color. Physician in facility at time of assessment and made aware of findings. The change of status was identified at 6:00 AM and the facility did not consult the Physician until 10:00 AM when the facility got an order to send R298 out.
The facility failed to immediately consult the Physician after a change in condition seen after an unwitnessed fall.
1/25/23 at 3:05 PM- E1 (NHA) and E2 (DON) were informed of the findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0646
(Tag F0646)
Could have caused harm · This affected 1 resident
Based on interview and record review, it was determined that for one (R14) out of one sampled resident reviewed for PASARR (Preadmission Screening & Resident Review), the facility failed to refer R14 ...
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Based on interview and record review, it was determined that for one (R14) out of one sampled resident reviewed for PASARR (Preadmission Screening & Resident Review), the facility failed to refer R14 to the appropriate State-designated authority for a Level II PASARR evaluation and determination after R14 was given a new diagnosis and prescribed medication that would require a new PASARR. Findings include:
R14's clinical record revealed:
R14's PASARR Level I, completed by the hospital on 8/9/19 noted, Indication of mental illness, mental retardation/related conditions but meets physician's exemption criteria. R14 was admitted to the facility with a diagnosis of anxiety disorder.
6/18/20- R14 was care planned for alterations in mood and behaviors as evidenced by hallucinations, talking into remote due to psychosis.
6/30/20- During a Neurology phone consult, R14 was diagnosed with visual hallucinations and delusions and was prescribed Seroquel, an antipsychotic medication, by E15 (Neurology NP). E15's consult note documented that the former Nursing Director was Most worried about her hallucinations and delusions. These have been a problem for the past couple of months.
1/25/23 at 9:28 AM- During a combined interview with E1 (NHA), E2 (DON) and E19 (Regional Clinical Nurse Specialist), the Surveyor reviewed the findings and asked if another PASARR evaluation was completed since R14's new psych diagnosis and use of antipsychotic medication on 6/30/20. No further information was received by the Surveyor.
1/26/23 from 1:20 PM to 2:15 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E19 (Regional Clinical Nurse Specialist).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined that for one (R44) out of one death record reviewed the facility failed to ensure that the baseline care plan was developed within 48 hours of a...
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Based on record review and interview, it was determined that for one (R44) out of one death record reviewed the facility failed to ensure that the baseline care plan was developed within 48 hours of admission and failed to have evidence that the resident/responsible party was provided the baseline care plan summary. Findings include:
10/22/22 - R44 was admitted to the facility.
10/25/22- Care plans were created for R44.
1/24/23 at 2:24 PM - Review of R44's clinical record lacked evidence of a baseline care plan and that a care plan summary was provided to the resident/responsible party.
1/24/23 4:46 PM - During an interview with E2 (DON), E2 confirmed the absence of a baseline care plan for R44.
1/26/23 from 1:20 PM to 2:15 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 and E19 (Regional Clinical Nurse Specialist).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview, it was determined that the facility failed to revise the advanced directive care plan for one (R15) out of 14 sampled residents to reflect the curren...
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Based on observation, record review and interview, it was determined that the facility failed to revise the advanced directive care plan for one (R15) out of 14 sampled residents to reflect the current code status order. Findings include:
1. Review of R15's clinical record revealed:
11/7/22- R15's advanced directives care plan listed the following interventions: The resident has an advanced directive(s) and has documentation in their medical record r/t Code status: Full code. The residents wishes will be honored and maintained through the next review date, honor the resident choice for code status, monitor for decline with the resident's health status, and Report findings to the MD.
4/28/22- R15's code status changed from a full code to a Do Not Resuscitate (DNR) and was signed by the Power of Attorney (POA) and the Facility Representative, E21 (SW).
5/5/22- A Physician's DNR code status order was written.
1/24/23 at 2:14 PM- An interview with E21 confirmed findings. E21 stated the facility's Interdisciplinary Team (IDT) was responsible for updating the residents care plan. E21 stated, Right now we have him as a DNR, but the care plan needs to be updated. Anyone from IDT can update the advanced directives, but I can do it myself. I think I actually put the wrong one in.
Despite R15's updated code status signed by the POA and the Facility Representative (E21) on 4/28/22 and an updated code status order of DNR by the Physician on 5/5/22, the facility failed to revise R15's code status in his care plan. The care plan remained full code until 1/24/23 at 2:14 PM when it was updated by E21 post interview with the Surveyor.
1/26/23 beginning at approximately 1:20 PM- Findings were reviewed with E1 (NHA) AND E2 (DON).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on resident interview and observation, the facility failed to ensure that one (R15) out of three sampled residents reviewed for Activities of Daily Living (ADLs) received the necessary services ...
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Based on resident interview and observation, the facility failed to ensure that one (R15) out of three sampled residents reviewed for Activities of Daily Living (ADLs) received the necessary services to maintain appropriate care for toileting. R15 waited from 9:30 AM to 10:23 AM for incontinence care. Findings include:
Review of R15's clinical record revealed:
4/27/21- R15 was admitted to the facility with a past medical history including Chronic Kidney Disease and the need for assistance with incontinence care.
11/7/22- R15's ADL care plan revealed, The resident requires extensive assist of 1-2 staff for toileting.
1/19/23 at 9:37 AM- During an interview with R15, he stated, I lay in poo (stool) over an hour many times and the staff says to me . 'We have other people to take care of.' I felt disgusting [it] dries up and cakes up, I have to go through two pants a day because the urine goes through the diaper.
1/24/23 at 10:02 AM- R15 approached the Surveyor in his wheelchair and stated that he had been waiting since 9:30 AM to get changed and he was upset because activities start at 10:30 AM and now he'll miss the music activity. E23 (LPN) approached the Surveyor and R15 and E23 stated that the CNA was in another room taking care of someone else. E23 walked away from the resident down each hall in search of an available CNA and once unable to find anyone, E23 proceeded with medication administration in the 700 Hall. R15 stated, They turned off my call light and I am turning it back on I still have poop in my pants!
1/24/23 at 10:06 AM- R15 turned his call light back on.
1/24/23 10:08 AM- E23 (LPN) was observed by the Surveyor entering R15's room to provide him medication while R15 remained sitting in his wheelchair soiled.
1/24/23 10:12 AM- E23 left R15's room after administering his medication with the call light still on and with the resident still unchanged sitting in his stool.
1/24/23 10:14 AM- R15 wheeled over to the Surveyor and stated, She (E23) didn't do nothing but spill ginger ale and water all over the place and that's what was taking her so long to clean it up, I am still waiting to be changed. E23 told R15 that the CNA was with another resident right now.
1/24/23 10:23 AM- E24 (CNA) entered R15's room with a sit to stand device. E23 followed behind.
1/24/23 10:34 AM- The Surveyor asked E24 how long it usually takes to receive help with incontinence care. E24 stated, Not long, if someone is caring for another resident someone will come get you to let you know who is waiting and R15 did not wait long.
1/24/23 10:39 AM- Once incontinence care was completed, R15 stated to the Surveyor It took 1 hour and 15 minutes to be seen with poop on me! R15 confirmed that this happens often and sometimes he has to wait even longer. The actual time waiting was 53 minutes.
1/26/23 beginning at approximately 1:20 PM- Findings were reviewed with E1 (NHA) AND E2 (DON).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of R298's clinical record revealed:
R298 was admitted to the facility on [DATE] with a past medical history including ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of R298's clinical record revealed:
R298 was admitted to the facility on [DATE] with a past medical history including Congestive Heart Failure, Dementia, and a history of falling.
11/7/22 at 12:00 PM- R298 was found lying on the floor face up on her back. The fall was unwitnessed.
11/7/22- Review of the facility's Neurological Evaluation Flow Sheet from 12:00 PM - 11:38 PM, after R298's unwitnessed fall, revealed that the facility failed to complete Neurocheck assessments in their entirety post fall. The Glasgow Coma Scale (GCS) total was blank for the entire first day post fall. The GCS total is used to assess for signs of brain injury. Additionally, the Neurological Evaluation Flow Sheet, also showed that the Respiratory Pattern was inconsistently completed. The Neurological Evaluation Flow Sheet was completed for 11/8/2022.
1/25/23 at 3:05 PM- E1 (NHA) and E2 (DON) were informed of the findings.
Based on policy and record review, observations and interviews, it was determined that for three (R3, R7 and R298) out of 14 sampled residents reviewed for care, the facility failed to ensure that R3, R7 and R298 received care that was consistent with Physician's orders and facility policy. Findings include:
1. Review of R3's clinical record revealed:
2/12/22 - R3 was admitted to the facility with multiple diagnoses, including vascular dementia and muscle atrophy (decreasing size).
11/3/2022 - A physician's order was written to insert a washcloth beneath R3's chin for protection every shift.
1/24/23 - A progress note by E20 (NP) stated that R3 keeps her chin against her chest and that R3 has redness and MASD (moisture associated skin damage) on the front of her neck.
R3 was observed on 1/20/23 at 8:30 AM, 1/23/23 at 9:20 AM, 1/24/23 at 10:00 AM and 1/26/23 at 8:30 AM without a washcloth under her chin.
1/26/23 8:30 AM - During an interview, E2 (DON) confirmed that a washcloth was not under R3's chin.
2. Review of R7's clinical record revealed:
12/2/22 - R7 was admitted to the facility.
1/12/23 - A progress note by E28 (NP) stated that R7's hearing was reduced and that an exam revealed impacted ear wax in both ears; to start Debrox and will flush ears as needed.
1/12/23 - A physician's order was written for Debrox Solution 6.5% - instill 5 drops in both ears two times a day for excess ear wax for 4 days.
Review of R7's Electronic Medical Record (EMR) revealed that R7 did not receive the Debrox Solution from 1/12/23-1/16/23 because the medication was not available from the pharmacy. The Debrox Solution order was automatically discontinued in the EMR on 1/16/23, the order end date.
1/23/23 2:00 - During an interview, E2 (DON) confirmed that R7 did not receive the Debrox Solution from 1/12/23-1/16/23 or to date because of a pharmacy delayed medication delivery.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on record reviews and review of facility documentation, it was determined that for two (R15 and R25) out of five residents reviewed for unnecessary medications, the facility failed to ensure tha...
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Based on record reviews and review of facility documentation, it was determined that for two (R15 and R25) out of five residents reviewed for unnecessary medications, the facility failed to ensure that the Attending Physician reviewed the Medication Regimen Review (MRR) timely. Findings include:
Review of R15's clinical record revealed:
1. 3/5/22- A pharmacy consultation report for R15 read, Comment: [R15] was recently initiated on fexofenadine 180 GIVE 1 TABLET BY MOUTH ONE TIME A DAY FOR RASH FOR 7 DAYS and had an estimated CrCl (Creatinine Clearance) of 50 ml/min (milliliters per minute) on 3/5/22, which may increase the risk of potential adverse events (e.g. [for example], sedation, falls). Recommendation: Please consider reducing the dose of 60 mg (milligrams) once daily. Reducing the dose of fexofenadine/pseudoephedrine 12 hour to one tablet once daily. The MRR lacked evidence that the Attending Physician reviewed or signed the MRR as of 1/25/23.
8/22/22- A pharmacy consultation report for R15 read, Comment: [R15] has received a combination topical anti-infective/corticosteroid product, lotrisone being applied twice daily for greater then 8 weeks without a documented stop date/ since 6/13/22. Recommendation: Please discontinue lortisone. If therapy cannot be discontinued, please document stop date. The Attending Physician reviewed and signed the MRR on 1/25/23, approximately five months after the recommendation.
2. Review R25's clinical record revealed:
12/14/22- A pharmacy consultation report for R25 read, Comment: [R25] has a recent order for oseltamivir 75 mg daily for influenza prophylaxis and had had an estimated CrCl of 49 mL/milliliters on 9/21/21. Recommendation: Please reduce dose of oseltamivir to 30mg daily for the remaining treatment period. The Attending Physician reviewed and signed the MRR on 1/25/23, more than a month later.
8/17/22- A pharmacy consultation report for R25 read, Comment: [R25] continues to receive probiotic (microorganisms that are intended to have gut health benefits when consumed) therapy with probiotic, since 4/21. Recommendation: Please consider discontinuation. The Attending Physician authorized the MRR on 1/25/23, approximately five months after the recommendation.
1/26/23 beginning at approximately 1:20 PM- Findings were reviewed with E1 (NHA) AND E2 (DON).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on record reviews, interviews, and review of facility documentation, it was determined that for one (R15) out of five residents sampled for medication review, the facility failed to monitor uric...
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Based on record reviews, interviews, and review of facility documentation, it was determined that for one (R15) out of five residents sampled for medication review, the facility failed to monitor uric acid levels for a resident on gout medication. Findings include:
Review of R15's clinical record revealed:
11/7/22- A Medication Regimen Review for R15 includes, REPEATED RECOMMENDATION from 8/22/22: Please respond promptly to assure facility compliance with Federal regulations. Please monitor a serum uric acid concentration on the next convenient lab day and every six months. Medications used in management of gout are recommended at doses which maintain a serum uric acid concentration below 6mg/dL.
11/9/22- R15's Physician accepted the recommendation(s) to be implemented as written.
The facility was unable to provide evidence that a Physician's order was submitted and was unable to provide evidence that the labs were completed.
The facility failed to monitor the gout medication for R15 as recommended by the Pharmacist and approved by the Physician.
1/25/23 at 11:40 AM- Findings were confirmed by E19 (Regional Clinical Nurse Specialist) and E2 (DON) was present.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on clinical record review, observation and interview, it was determined that for one (R17) of 28 medication (med) administration opportunities during the med pass, the facility failed to have a ...
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Based on clinical record review, observation and interview, it was determined that for one (R17) of 28 medication (med) administration opportunities during the med pass, the facility failed to have a current label in accordance with the Physician's order for a med with blood pressure (BP) parameters of when to hold the medication. Findings include:
1/17/23- A physician's order was written for Midodrine HCL (used for low BP by raising the BP) 5 mg give two tablets three times a day and hold for a systolic (top number) BP (SBP) greater than 140.
1/24/23 8:20 AM- E27 (RN Supervisor) obtained R17's BP.
1/24/23 at approximately 8:35 AM- The Surveyor observed the blister pack of Midodrine for R17. The parameter on the label stated to hold for a BP greater than 130/90. When questioned, R27 stated the Physician order in the electronic Medication Administration Record (eMAR) was to hold for the med for a SBP greater than 140.
1/24/23 at approximately 8:40 AM- E27 administered the Midodrine.
1/24/23 9:45 AM- After verifying the eMAR Midodrine order, findings were discussed and confirmed with E27 that the current Midodrine label was incorrect. E27 stated that she'd get a new label.
1/26/23 from 1:20 PM to 2:15 PM- Findings were reviewed during the exit conference with E1 (NHA) E2 (DON) and E19 (Regional Clinical Nurse Specialist).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined that the facility failed to have an Infection Preventionist participate on the QAPI (Quality Assurance and Performance Improvement) committee. A...
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Based on record review and interview, it was determined that the facility failed to have an Infection Preventionist participate on the QAPI (Quality Assurance and Performance Improvement) committee. Additionally, the facility failed to have quarterly QAPI meetings in 2022. Findings include:
1/26/23 - Review of the facility QAPI Team Members list does not include an Infection Preventionist.
1/26/23 - Review of the 2022 quarterly QAPI meeting attendance sheets revealed a missing attendance sheet for quarter two (April, May and June).
1/26/23 - During an interview, E2 (DON) confirmed that the facility did not have a QAPI meeting in quarter two of 2022.
1/26/23 from 1:20 PM to 2:15 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 and E19 (Regional Clinical Nurse Specialist).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0943
(Tag F0943)
Could have caused harm · This affected 1 resident
Based on interview and review of facility documentation, it was determined that the facility failed to ensure that required training for abuse, neglect, and exploitation training was completed for one...
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Based on interview and review of facility documentation, it was determined that the facility failed to ensure that required training for abuse, neglect, and exploitation training was completed for one (E26) out of 10 randomly sampled staff members. Findings include:
Review of E26's personnel records revealed:
3/14/19- E26 worked her first assignment in the facility.
4/23/20- E26's Abuse, Neglect, and Exploitation Training was completed.
1/20/23- E25 (HR Director) completed the Staff Training and Vaccination packet, however, annual Abuse, Neglect, and Exploitation Training documentation was outstanding for E26. It was last completed on 4/23/20.
1/25/23 at 3:05 PM- E2 (DON) and E1 (NHA) confirmed findings.
1/26/23 at 8:22 AM- Documents that were left for the Surveyor revealed updated Abuse, Neglect, and Exploitation Training for E26. The training was signed and dated 1/23/23 by E26, after E25 completed the initial Staff Training and Vaccination packet and was provided the random selection of employees. E26 was due for her annual abuse training since 4/23/21 and was not provided the annual Abuse training until 1/23/23 during the facility's survey.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected multiple residents
Based on interview and review of facility documentation as indicated, it was determined that the facility failed to have an Infection Preventionist (IP) responsible for the facility's IPCP (Infection ...
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Based on interview and review of facility documentation as indicated, it was determined that the facility failed to have an Infection Preventionist (IP) responsible for the facility's IPCP (Infection Prevention and Control Program) that had completed specialized training in infection prevention and control from 9/1/22 to 1/3/23, approximately 4 months. Findings include:
1/19/23 - In response to documentation requests during the Survey's Entrance Conference, the facility provided evidence of specialized infection prevention and control training of E4, who was hired on 1/4/23 as the facility's IP.
1/25/23 at 1:15 PM - During an interview, E2 (DON) stated that she took over the IP role after E30 (former DON) left the faciity on 8/31/22. E2 confirmed that she did not have specialized training in infection prevention and control.
1/26/23 from 1:20 PM to 2:15 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 and E19 (Regional Clinical Nurse Specialist).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0885
(Tag F0885)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review of facility documentation, it was determined that the facility failed to inform residents, their r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review of facility documentation, it was determined that the facility failed to inform residents, their representatives, and families after infections of COVID-19 of one resident on 1/1/23 and one staff member on 1/16/23 by 5:00 PM the next calendar day. Findings include:
1/19/23 - In response to the Survey's Entrance Conference request for facility documentation, the facility provided a handwritten response that stated: The facility's mechanism use to inform residents, their representatives and families of confirmed or suspected COVID-19 activity in the facility is via (by) email.
Review of the facility's line listing for the past four weeks revealed:
-1/1/23, one resident tested positive for COVID-19; and
-1/16/23, one staff person tested positive for COVID-19.
The facility lacked evidence that residents, their representatives, and families were informed by 5:00 PM the next calendar day by email after each positive COVID-19 individual.
1/25/23 at 10:45 AM - During a combined interview, E4 (IP) and E31 ([NAME] Living ADON) confirmed the finding.
1/26/23 from 1:20 PM to 2:15 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E19 (Regional Clinical Nurse Specialist).
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
Based on observations and interview, it was determined that the facility failed to ensure that the kitchen was maintained to ensure proper food safety. Findings include:
The following were observed d...
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Based on observations and interview, it was determined that the facility failed to ensure that the kitchen was maintained to ensure proper food safety. Findings include:
The following were observed during the kitchen tour on 1/19/23 from 8:45 AM to 10:00 AM:
- The hand washing sink paper towel dispenser was dispensing too much paper towel causing the clean paper towel to dispense into the hand sink, thus contaminating paper towels;
- The light cover in the dry storage room, handwashing station by the dry storage room, and loading bay were in disrepair;
- The loading bay door sweep was in disrepair creating gaps for pests.
Findings were reviewed and confirmed with E22 (Food Service Director) on 1/19/23 at approximately 10:00 AM.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review of the clinical record and facility documentation as indicated, the facility failed to have an eff...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review of the clinical record and facility documentation as indicated, the facility failed to have an effective Infection Prevention and Control Program surveillance system that identified, tracked, monitored and/or reported infections from January 1, 2022 through April 30, 2022. In addition, the facility's surveillance system for the subsequent months were incomplete with missing data and lacked evidence of an ongoing analysis of the data and documentation of follow-up activity. Findings include:
Cross refer F882
Sept. 2017 last revised - The facility's policy entitled Surveillance for Infections stated, The infection preventionist will conduct ongoing surveillance for healthcare-associated infections and other . significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions . Gathering Surveillance Data 1. The infection preventionist . is responsible for gathering and interpreting surveillance data. The infection control committee and/or QAPI (Quality Assurance Performance Improvement) committee may be involved in interpretation of the data . Interpreting Surveillance Data 1. Analyze the data to identify trends .
From January 1, 2022 through April 30, 2022, the facility lacked evidence of any infection control surveillance data, analysis and follow-up documentation.
May 2022 - The facility implemented a new Infection Control software tool to assist in tracking facility infections through an Infection Control Data Log, which included, but was not limited to, data collection of the identified pathogens, antibiotic therapy ordered, infections that are reportable to the State, and calculated infection rates.
Review of the monthly Infection Control Data Logs from May 2022 through December 2022 revealed missing data, including the identified pathogens, and lack of evidence of monthly infection rates, analysis and recommendations. An example of missing data on the October 2022 Infection Control Data Log included that the facility failed to capture R34's treatment of fungal dermatitis for four days (10/6/22 through 10/9/22).
1/25/23 at 10:45 AM - During a combined interview, E4 (IP) and E31 ([NAME] Living ADON) confirmed the findings.
1/26/23 from 1:20 PM to 2:15 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E19 (Regional Clinical Nurse Specialist).
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review of facility documentation, the facility failed to have an ongoing facility-wide antibiotic steward...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review of facility documentation, the facility failed to have an ongoing facility-wide antibiotic stewardship program from January 2022 through December 2022. Findings include:
Cross refer to F880, F882
12/2016 last revised - The facility's policy entitled Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes stated, . As part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the infection preventionist (IP), or designee . identify specific situations that are not consistent with the appropriate use of antibiotics . 4. All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form .
12/2016 last revised - The facility's policy entitled Antibiotic Stewardship - Staff and Clinician Training and Roles stated, . The IP will monitor over time and report to the IPCC (Infection Prevention and Control Committee): a. measures of antibiotic use . b. antibiotic susceptibility patterns . c. negative outcomes or events related to antibiotic use, for example: (1) C. difficile infections; (2) adverse drug events; and (3) antibiotic resistance rates .
1/25/23 at 10:45 AM - During a combined interview, E4 (IP) and E31 ([NAME] Living ADON) confirmed the finding. The facility lacked evidence of an ongoing antibiotic stewardship program from January 2022 through December 2022.
1/26/23 from 1:20 PM to 2:15 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E19 (Regional Clinical Nurse Specialist).
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0886
(Tag F0886)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review of facility and State of Delaware's Department of Public Health (DPH) documentation, it was determ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review of facility and State of Delaware's Department of Public Health (DPH) documentation, it was determined that the facility failed to conduct COVID-19 testing of staff and residents in response to a positive resident on 1/1/23 and a positive staff member on 1/16/23 according to the State of Delaware COVID-19 infection guidance. Findings includes:
1/3/23 at 6:20 AM - Based on the facility reporting a COVID-19 positive resident, an email was sent to E2 (DON) from the State of Delaware's DPH that outlined recommended general guidance that included testing of residents/staff.
1/17/23 at 1:40 PM - Based on the facility's reporting of a COVID-19 positive staff member, an email was sent to E25 (HR Director) from the State of Delaware's DPH that outlined recommended general guidance that included testing of residents/staff.
1/25/23 at 10:45 AM - During a combined interview with E4 (IP), E31 ([NAME] Living ADON) and E2 (DON), E2 (DON) stated that during the first outbreak on 1/1/23, the facility conducted focused-testing of staff as the resident never left the room. The Surveyor asked to review the documentation of staff testing and no documentation was provided. There was no evidence of focused outbreak testing of staff completed on Day 1, Day 3, Day 5, and Day 8-14. During the second outbreak when a staff member tested COVID-19 positive on 1/16/23, the facility conducted broad-based testing of staff/residents on Day 1 and provided the Surveyor with testing evidence. However, the facility lacked evidence of broad-based testing of staff/residents on Day 3 and Day 5. Two additional residents tested COVID-19 positive on 1/23/22 and broad-based testing of staff/residents was conducted on 1/24/23, which covered the Day 8-14 testing requirement from the second outbreak. E4 and E31 confirmed the findings.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observation, review of facility documentation and staff interviews, it was determined that for five out of six days, the facility failed to ensure that the credentials of staff were written o...
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Based on observation, review of facility documentation and staff interviews, it was determined that for five out of six days, the facility failed to ensure that the credentials of staff were written on the posted schedules in the only nurses station. Findings include:
1/25/23 at 2:13 PM- Review of the posted staff schedules from 1/19/23 through 1/25/23 revealed that the facility failed to consistently list the credentials of staff working in the facility.
1/25/23 at 2:17 PM- E2 (DON) confirmed findings.
1/26/23 at 8:19 AM- During an interview with E2, E2 stated the computer was cutting off the staff's credentials if the employee had a long name. E2 subsequently corrected the posted staff schedule for 1/26/23 by writing in the staff's credentials.
Nov 2019
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, record review and staff interview, it was determined that for two (R11 and R33) out of two residents reviewed for respiratory care, the facility failed to maintain respiratory eq...
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Based on observation, record review and staff interview, it was determined that for two (R11 and R33) out of two residents reviewed for respiratory care, the facility failed to maintain respiratory equipment. Findings include:
1. The following was reviewed in R11's clinical record:
8/22/19 - The quarterly MDS for R11 had a medical history that included asthma and COPD.
On 10/29/19 at 10:09 AM, R33 was observed with oxygen via nasal cannula. No date was observed on the oxygen tubing.
2. The following was reviewed in R33's clinical record:
4/5/19 - The annual MDS for R33 had a medical history that included respiratory failure.
On 10/29/19 at 10:11 AM, R33 was observed with oxygen via nasal cannula at 6 liters. No date was observed on the oxygen tubing.
During an interview on 11/1/19 at approximately 9:45 AM, E2 (DON) stated that the policy for oxygen tubing is to change the tubing and date weekly on Saturday evening on the 11:00 PM to 7:00 AM shift.
These findings were reviewed during the exit conference on 11/1/19 at 2:45 PM with E1 (NHA) and E2 (DON).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
Based on record review and interview it was determined that for one (R37) out of one resident reviewed for pain management and one (R42) out of five residents reviewed for unnecessary medication the f...
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Based on record review and interview it was determined that for one (R37) out of one resident reviewed for pain management and one (R42) out of five residents reviewed for unnecessary medication the facility failed to ensure pain management was provided to the residents consistent with the residents' comprehensive person-centered care plan and physician's orders. For both residents the facility failed to attempt non-pharmalogical interventions prior to administering PRN pain medication. Findings include:
1. Review of R37's clinical record revealed:
9/19/19 - R37 was admitted to the facility.
9/26/19 - The admission MDS revealed that R37 received PRN pain medications and had not received non-medication intervention for pain.
The following PRN pain medications were ordered for R37 in September and October 2019:
9/19/19 - 9/20/19 - Oxycodone HCl as needed for moderate to severe pain.
9/20/19 - 10/7/19 - Ibuprofen as needed for mild pain.
9/20/19 - Oxycodone HCl as needed for moderate to severe pain for 14 days.
10/9/19 - Acetaminophen as needed for pain.
September 2019 and October 2019 MARs revealed that the above medications were administered on the following days:
9/19, twice on 9/20, 9/22, 9/23, twice on 9/24, twice on 9/25, 9/27, 9/29, 10/2 and 10/17
9/19/19 - An order was started for the documentation of Non-Pharmacological Pain Management Intervention 1= Deep Relaxation 2= Heat to the site 3= Cold/Ice to the site 4= Massage 5=Meditation 6=Music 7=Going to bed 8=Quiet Place 9=Repositioning 10= Aromatherapy 11= Guided imagery 12= Other.
9/19/19 - 10/30/19 - The MAR was left blank on each day for the above order.
Four times in September 2019 and October 2019 the PRN pain medications were administered and a progress note was written by a nurse that detailed the non-pharmalogical intervention used and its ineffectiveness prior to administering the medication.
9/19/19 - A care plan was initiated with a focus for R37 that included that the resident has increased risks for alteration in comfort d/t left leg pain d/t fracture with surgical repair of left tibia/fibula and upper back.
10/21/19 - The above mentioned care plan was revised to include an intervention that Repositioning improves my (R37's) pain.
10/31/19 11:45 AM - During an interview E2 (DON) confirmed that nothing was noted on the MAR and no progress notes could be found detailing non-pharmalogical pain interventions prior to using pain medication.
2. Review of R42's clinical record revealed:
10/11/19 - R42 was admitted to the facility.
10/11/19 - A care plan was initiated with a focus for R42 that included that the resident has increased risks for alteration in comfort d/t surgical incisions.
The care plan included the following interventions:
Anticipate the resident's need for pain relief and respond timely to any complaint of pain.
Pain medication is an effective way to provide me pain relief.
Deep relaxation techniques help me with pain relief.
Sleeping (going to bed) helps improve my pain.
A quiet room (quiet place) helps improve my pain.
Repositioning improves my pain.
Non-pharmacological interventions shall be attempted that work for me to decrease my pain. This would include, but not limited to snack, repositioning, resting in bed, increased socialization & participation in activities as a therapeutic use of distraction.
The following PRN pain medications were ordered for R42:
10/11/19 - 10/16/19 - Oxycodone HCl as needed for moderate to severe pain.
10/14/19 - Tylenol as needed for pain.
The October 2019 MAR revealed that the above medications were administered on the following days:
twice on 10/13, twice on 10/15, 10/19, 10/20, 10/22 and 10/23
10/11/19 - An order was started for the documentation of Non-Pharmacological Pain Management Intervention 1= Deep Relaxation 2= Heat to the site 3= Cold/Ice to the site 4= Massage 5=Meditation 6=Music 7=Going to bed 8=Quiet Place 9=Repositioning 10= Aromatherapy 11= Guided imagery 12= Other.
10/11/19 - 10/30/19 - The MAR was left blank on each day for the above order.
These findings were reviewed during the exit conference on 11/1/19 at 2:45 PM with E1 (NHA) and E2 (DON).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
4. The following infection prevention and control policies were not reviewed annually:
•
The facility policy, titled Infection Control Program, was last revised on 11/15/10. No review date was l...
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4. The following infection prevention and control policies were not reviewed annually:
•
The facility policy, titled Infection Control Program, was last revised on 11/15/10. No review date was located on the document.
•
The facility policy, titled Influenza, was last revised on 2/15/11. No review date was located on the document.
•
The facility policy, titled Pneumonia, was last revised on 2/15/11. No review date was located on the document.
•
The facility policy, titled Hand Washing, was last revised on 1/17/16. No review date was located on the document.
During an interview on 11/1/19 at 10:50 AM, E3 (Regional Director) confirmed that although the policies and procedures were reviewed annually, this was not recorded anywhere. There was no evidence that the policies and procedures of the infection prevention and control program were reviewed annually.
These findings were reviewed during the exit conference on 11/1/19 at 2:45 PM with E1 (NHA) and E2 (DON).
Based on observation, record review and interview it was determined that the facility failed to use appropriate hand hygiene practices when during medication administration observation and dressing change observation staff failed to perform hand washing for the minimum recommended timeframe of at least 15 seconds. Additionally, facility infection prevention and control policies were not updated annually. Findings include:
3/5/17 -The Centers for Disease Control and Prevention (CDC) article titled Clean Hands Count for Healthcare Providers states, .Hand hygiene means cleaning your hands by using either hand washing (washing hands with soap and water) .antiseptic hand rub (i.e. alcohol-based hand sanitizer including foam or gel) .Clean your hands: .Before and after having direct contact with a patient's intact skin .After contact with blood, body fluids or excretions .After contact with inanimate objects (including medical equipment) .After glove removal .Techniques for Washing Hands with Soap and Water: When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended .rub your hands together vigorously for at least 15 seconds, covering all surfaces .Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. Either time is acceptable . (https://www.cdc.gov/hand hygiene/providers/index.html).
The facility policy on handwashing, last updated 1/17/16 indicated that while performing hand washing rub hands together using friction for 20 seconds.
1. During a medication administration observation on 10/29/19 at 10:11AM, E5 (LPN) performed hand hygiene, specifically hand washing for a total of 9 seconds after applying a medicated patch to R3's skin. During that same observation at 10:13 AM E5 performed hand hygiene, specifically hand washing for a total of 10 seconds after administering a medication into R3's nose.
2. During a medication observation on 10/29/19 at 12:15 PM, E6 (LPN) did not perform any hand hygiene prior to administering an injection to R42.
3. During a dressing change observation on 10/31/19 at 10:36 AM, E4 (RN) completed incontinence care for R15, then, after removing gloves performed hand hygiene, specifically hand washing for a total of 6 seconds. During that same dressing change observation, E5 (LPN) completed R15's dressing change, then performed hand hygiene, specifically hand washing, for a total of 8 seconds.
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
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 1 harm violation(s), $32,394 in fines. Review inspection reports carefully.
- • 60 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $32,394 in fines. Higher than 94% of Delaware facilities, suggesting repeated compliance issues.
- • Grade F (38/100). Below average facility with significant concerns.
Bottom line: Trust Score of 38/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Shipley Living's CMS Rating?
CMS assigns SHIPLEY LIVING an overall rating of 3 out of 5 stars, which is considered average nationally. Within Delaware, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Shipley Living Staffed?
CMS rates SHIPLEY LIVING's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 51%, compared to the Delaware average of 46%.
What Have Inspectors Found at Shipley Living?
State health inspectors documented 60 deficiencies at SHIPLEY LIVING during 2019 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, 56 with potential for harm, and 2 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Shipley Living?
SHIPLEY LIVING is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 82 certified beds and approximately 61 residents (about 74% occupancy), it is a smaller facility located in WILMINGTON, Delaware.
How Does Shipley Living Compare to Other Delaware Nursing Homes?
Compared to the 100 nursing homes in Delaware, SHIPLEY LIVING's overall rating (3 stars) is below the state average of 3.3, staff turnover (51%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Shipley Living?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Shipley Living Safe?
Based on CMS inspection data, SHIPLEY LIVING has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Delaware. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Shipley Living Stick Around?
SHIPLEY LIVING has a staff turnover rate of 51%, which is 5 percentage points above the Delaware average of 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 Shipley Living Ever Fined?
SHIPLEY LIVING has been fined $32,394 across 2 penalty actions. This is below the Delaware average of $33,403. 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 Shipley Living on Any Federal Watch List?
SHIPLEY LIVING 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.