Delaware Court Health Care Center

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure fall interventions were in place as ordered. This affected one Resident (#39) out of four Residents (#6, #39, #51, and #58) reviewed for fall incidents and accident prevention. The facility census was 59. Findings Include:Review of the medical record for Resident #39 revealed the resident was admitted to the facility on [DATE]. Diagnoses included late onset Alzheimer's disease, dementia in other diseases, and anxiety disorder amongst other diagnoses. Further review of Resident #39's medical record revealed a Brief Interview for Mental Status (BIMS) score could not be evaluated as the resident was rarely or never understood as of the Minimum Data Set (MDS) 3.0 assessment completed on 04/03/26, though the resident was noted to have severe cognitive impairment. [...]

Inspectors wroteBased on record review, observation, resident and staff interview, the facility failed to address resident concerns brought up at the resident council meetings. This affected four Residents (#23, #27, #30, and #44). Facility census was 59. Findings Include:1. Review of the medical record for Resident #23 revealed an admission date of 09/09/25. Diagnoses included atrial fibrillation, pulmonary disease, dysphagia and fracture of the right foot. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition. 2. Review of the medical record for Resident #27 revealed an admission date of 10/02/24. Diagnoses included dementia, pulmonary disease, dysphagia and heart disease. [...]

Inspectors wroteBased on observations, interviews and facility policy review, the facility failed to ensure residents resided in a safe, clean and comfortable environment. This affected six residents (#3, #9, #27, #33, #41 and #50) of seven ( #21) reviewed for environmental concerns. The census was 59Findings Include:A facility tour conducted on 01/28/26 at 8:15 A.M. revealed all resident rooms, and the resident private dining room had a Packaged Terminal Air Conditioner (PTAC) unit (a self-contained heating and cooling unit in which offer individual room control ) . The temperature outside on this day was cold with daily highs in the mid to low teens and lows near or below zero Fahrenheit. Observation on 01/28/26 at 8:30 A.M. of the Resident Private Dining Room revealed the PTAC unit was installed below the room window. [...]

Inspectors wroteBased on medical record review, staff interview and policy review the facility failed to ensure proper indication of use for medication, and failed to ensure duplicate medication had maximum dosage for use indicated, this affected one resident (#36) of five reviewed for unnecessary medications. The facility also failed to ensure pain medications were ordered with parameters and administered appropriately. This affected two Residents (#10 and #36) of two reviewed for pain management. The census was 59. Findings Include: 1. Review of the medical record for Resident #36 revealed an admission date of 02/14/25. Diagnoses included dementia, cerebral infarct, fractured tibia, malnutrition, vascular disease and osteoporosis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 03 indicating impaired cognition. [...]

Inspectors wroteBased on observation, staff interviews and record review, facility failed to ensure food was served and at a safe and palatable temperature. This had the potential to affect all facility residents except Resident #2. Facility census was 59.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure puree food was made to the correct consistency. This affected six residents (#7, #21, #25, #28, #42, and #52) who had orders for puree food. Facility census was 59.

Inspectors wroteBased on observation, staff interviews, and policy review the facility failed to ensure food was stored in a safe and sanitary manner, failed to ensure proper hand hygiene was completed when making puree food, taking food temperatures and during tray line service and failed to ensure the kitchen maintained proper sanitation. This affected all Residents except Resident #2 who did not eat food from the kitchen. Facility census was 59.

Inspectors wroteBased on medical record review, and staff interview, this facility failed to ensure an updated Preadmission Screening and Resident Review (PASARR) was completed when a resident was diagnosed with a new mental illness diagnosis. This affected one (Resident #53) of the one resident reviewed for accurate PASARRs. The facility census was 59.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the Quality Assurance meetings occurred quarterly as required. This had the potential to affect all residents who reside in the nursing facility. The census was 59.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure that the shower rooms were maintained in a clean and sanitary condition. This was noted in all four of the facility's shower rooms and impacted all residents who used them (Residents #1, #2, #3, #4, #5, #6, #7, #8, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #24, #25, #26, #27, #28, #29, #30, #31, #33, #34, #35, #36, #37, #39, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, and #54). The facility census was 54.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure wound care was completed per physician orders. This affected one (#10) of three residents reviewed for wound care. The facility census was 46. Findings Include: Review of resident #10's medical record revealed and admission date of 01/23/18. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side, cardiomyopathy, chronic systolic congestive heart failure, hypertension, osteoarthritis of knee, abnormalities of gait and mobility, weakness, and atrial fibrillation with long term use of anticoagulants. Resident #10 was discharged to the hospital on [DATE] per her request. [...]

Inspectors wroteBased on Board of Executives of Long-Term Services and Supports (BELTS) website review review and staff interview, and BELTS Representative interview, the facility failed to ensure the Administrator had an active license. This affected all 52 residents in the facility during the annual survey. The census was 52.

Inspectors wroteBased on record review, policy review and staff interviews, the facility failed to ensure an infection surveillance plan was in place for identifying, tracking, and monitoring outbreaks. This had the potential to affect all 52 residents. Facility census was 52.

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure the plumbing equipment was maintained in a safe and sanitary conditions . This had the potential to affect 50 of 50 residents who receive meals from the kitchen. excluding two (#3 and #305) residents who recive tube feeding. The faciltiy census was 52.

Inspectors wroteBased on financial records, Personal Needs Account Procedures review and staff interviews the facility failed to ensure resident care needs account was in an interest-bearing account. In addition, none of the 12 residents or their representatives signed an authorization form for the facility to handle their personal care need accounts. This affected all 12 (#36, #11, #5, #29, #7, #15, #14, #13, #42, #44, #34 and #33) residents personal care need accounts which the facility is representative payee. The census was 52.

Inspectors wroteBased on financial record reviews, resident interviews and staff interviews, the facility failed to ensure residents receive a quarterly statement for their personal care need account. This affected 12 (#36, #11, #5, #29, #7, #15, #14, #13, #42, #44, #34 and #33) of 12 residents with personal care need accounts. The census was 52.

Inspectors wroteBased on observations, medical record reviews, dentist roster review, Dental Mobile Office Representative interview, resident interview and staff interviews, the facility failed to offer dental services to residents. This affected one (#13) of one resident reviewed for dental services. This had the potential to affect 20 (#1, #3, #5, #36, #8, #10, #11, #13, #14, #15, #16, #17, #22, #24, #26, #27, #29, #34, #36, #42 and #46) additional resident who consented to see the dentist. The census was 52.

Inspectors wroteBased on record review, staff interview, email communication review and policy review, the facility failed to ensure antibiotics were ordered and used appropriately for residents with potential infections. This affected four (#21, #35, #37, #47) of four residents reviewed for antibiotic stewardship. Facility census was 52.

Inspectors wroteBased on financial record reviews and staff interview, the facility failed to ensure residents who are insured by Medicaid do not exceed $2,000.00 in their personal care needs accounts. This affected three Medicaid residents (#7, #11 and #36) of three accounts reviewed with funds above the $2,000.00 limit. The census was 52.

Inspectors wroteBased on record review, policy review and staff interview, the facility failed to ensure a residents code status was accurately reflected in the medical record. This affected one (#10) of two residents reviewed for advanced directives. The facility census was 52.

Inspectors wroteBased on staff interview, record review and policy review, the facility failed to ensure beneficiary notices were provided prior to a reduction of skilled services. This affected one (#206) of two residents reviewed for beneficiary notices. The facility census was 52.

Inspectors wroteBased on medical record review, resident interview, staff interview, statement reviews, and policy review, the facility failed to report an alleged allegation of abuse, neglect, and misappropriation to the state agency. This affected one (#21) of one resident reviewed for abuse/neglect. The facility census was 52.

Inspectors wroteBased on record review, resident interview, statement review, staff interview and review policy, the facility failed to complete a thorough investigation for an alleged allegation of abuse, neglect, and misappropriation. This affected one (#21) of one resident reviewed for abuse/neglect. The facility census was 52.

Inspectors wroteBased on medical record review, review of facility communication emails, review of policy, and staff interview, the facility failed to notify the Ombudsman when residents were transferred/discharged from the facility. This affected two (#52 and #53) of two residents reviewed for discharge home. The facility census was 52.

Inspectors wroteBased on medical record review and staff interview, the facility failed to have a care plan for a psychotropic medication. This affected one (#305) of five residents reviewed for unnecessary medications. The facility census was 52.

Inspectors wroteBased on medical record review, staff interviews and policy review, the facility failed to ensure a recapitulation of the resident's stay was provided when residents were discharge from the facility This affected two (#52 and #53) of two residents reviewed for discharged . The census was 52.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure pharmacy recommendations were reviewed timely by a physician and also failed to ensure recommendations reviewed had the recommendations acted upon as agreed upon by the physician. This affected two (#36 and #38) of five residents reviewed for pharmacy recommendations. Facility census was 52.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident was free from unnecessary medication. This affected one (#3) of six residents reviewed for unnecessary medication. The facility census was 52.

Inspectors wroteBased on observations, policy review and staff interviews, the facility failed to ensure the texture of a modified diet was provided to the physician ordered consistency. This affected (#3) one of one residents reviewed for a modified diet. The census was 52.

Inspectors wroteBased on observation, medical record review, resident interview, and staff interviews, the facility failed to ensure call lights were in proper working order. This affected one (#5) of one resident reviewed for environment. Facility census was #52.

Inspectors wroteBased on record review, staff interview, and review of the facility policy, the facility failed to ensure advanced directives for the code status were signed by the physician. This affected two (#7 and #20) residents reviewed for code status in a total facility census of 47.

Inspectors wroteBased on record review, staff interview and review of an undated form titled, Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, the facility failed to ensure appropriate beneficiary notices were provided to residents. This affected one (#295) of three residents reviewed for provision of beneficiary notices. The facility census was 47.

Inspectors wroteBased on record review, interviews with staff and residents, and review of the facility policy's, the facility failed to ensure care plans were revised to include an accurate code status, updated fall interventions, and updated dental concerns. This affected three (#9, #16 and #37) of sixteen residents reviewed for revision of care plans. Additionally, the facility failed to ensure care conferences were conducted. This affected one (#10) of one resident reviewed for care conferences. The facility census was 47.

Inspectors wroteBased on record review, observations, staff interview, and review of the facility policy, the facility failed to ensure fall interventions were implemented. This affected one (#9) of two residents reviewed for implementation of fall interventions. The facility census was 47.