Excelcare at Wilmington LLC

Inspectors wroteBased on record review and interview, it was determined that for one (R1) out of nine residents reviewed for resident rights, the facility failed to initiate a PASARR (Pre-admission Screening and Resident Review) review when R1 was started on a new anti-psychotic medication.

Inspectors wroteBased on record review and Interview, it was determined that for two (R1 and R2) out of nine residents reviewed for resident rights, the facility failed to ensure the medical records were in accordance with professional standards by being accurate.1. Review of R1's clinical record revealed:7/7/23 - R1 was admitted to the facility with diagnoses, including bit was not limited to, bipolar disorder.8/29/25 11:45 AM - From reading the facility's investigation report, there was a heated interaction between R1 and R4 during a room change. 8/29/25 2:53 PM - E8 (LPN) documented in R1's progress notes, Incident note: Officer [name] responded to the facility and interviewed [R1]. No case number is being assigned at this time.8/29/25 - E8 (LPN) documented in R1's Behavior Monitoring Record under Psychotropic use target behavior: agitation. [...]

Inspectors wroteBased on observations, interviews, record review, policy review, and review of the facility's investigations, the facility failed to ensure four of five residents reviewed for abuse prevention (Resident (R) 8, R183, R184, and R286) out of 28 sampled residents were free from abuse from other residents. R184 verbally abused R183 when attempting to take R183's walker believing it was his. R8 slapped R286 when attempting to take a magazine away from R286. The verbal and physical abuse from R183 and R286 created the potential for fear, pain, and injury to R184 and R8.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure residents were free from physical abuse from: 1. one resident (Resident (R) 95) who demonstrated repeated acts of physical violence towards multiple other residents to include residents R24 and R109; and 2. R128's wandering behavior resulted in a resident-to-resident abuse between R128 and R6. The facility's Administrator was informed on 02/29/24 at 3:40 PM that Immediate Jeopardy (IJ) existed at F600-K Freedom from Abuse and Neglect when the facility failed to implement effective interventions to ensure residents were free from abuse from R95. The facility provided an acceptable removal plan for the Immediate Jeopardy on 03/01/24 at 12:21 AM. The survey team validated that the Immediate Jeopardy was removed on 03/01/24 at 1:45 PM. [...]

Inspectors wroteBased on observations, interview, record reviews, and facility policy review, the facility failed to ensure four out of four isolation carts were fully stocked with the supplies needed to promote infection control, Resident (R) 30 did not consume a pill dropped on the ground, and staff utilized proper hand hygiene after wiping R116's nose of 41 sampled residents.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure one resident (Resident (R)106) out of a total sample of 41 residents was treated with dignity in toileting.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to timely report to the state survey agency multiple incidents of abusive behavior of one resident (Resident (R) 95) out of a total sample of 41 residents.

Inspectors wroteBased on record review, interview, document review, and policy review, the facility failed to conduct a thorough investigation for multiple incidents of abusive behavior of one resident (Resident (R) 95) out of a total sample of 41 residents.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure one of one resident (Resident (R) 106) was on a toileting program to enhance his continence out of 41 sampled residents

Inspectors wroteBased on observation, record review, interviews, review of facility provided incident (FRI), and review of facility policy, the facility failed to ensure that one of five residents (Resident (R) 32) reviewed for unnecessary medications out of 41 sampled residents, were free from unnecessary medications. R32 was administered another resident's (R9) medications resulting in a potential for R32 to have an adverse effect. In addition, two of five residents (R30 and 44) observed during medication administration, were not identified using two of four identifiers.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to maintain safe water temperatures for the sinks in resident bathrooms and a shower room on one out of three resident units. Additionally, one out of four of the facility's boilers was set to 141 degree's.

Inspectors wroteBased on observation and interview, it was determined that for one (R107) out of six residents reviewed for ADL's, the facility failed to ensure dignity when a soiled blanket was observed on the resident.

Inspectors wroteBased on interview and review of facility documentation, it was determined that for one (R98) out of three Medicare Part A discharges reviewed, the facility failed to provide notice to R98's financial Power of Attorney (POA) regarding the discontinuation of his Medicare Part A coverage for skilled services. Additionally, the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) forms were left unsigned with a handwritten note that stated the resident refused to sign.

Inspectors wroteBased on observation and interview it was determined that for two (100 and 200) out of three units toured, the facility failed to ensure areas were in good repair.

Inspectors wroteBased on interview, record review and review of other facility documentation, it was determined that for one (R7) out of one sampled resident reviewed for grievances, the facility failed to ensure that concerns received by the facility included prompt efforts to resolve the problems.

Inspectors wroteBased on record review and interview, it was determined that for one (R47) out of 33 sampled residents, the facility failed to have a MDS (Minimum Data Set) assessment that accurately reflected R47's oral cavity assessment when her use of the upper partial denture was not accurately coded.

Inspectors wroteBased on record review and interview, it was determined that for one (R53) out of 33 sampled residents for care plan investigations, the facility failed to ensure that the required interdisciplinary team (IDT) members participated in the care plan meetings.

Inspectors wroteBased on observation, interview and record review, it was determined that for one (R88) out of six residents reviewed for ADL (Activities of Daily Living), the facility failed to provide nail care.

Inspectors wroteBased on observation, interviews, and record review, it was determined that for one (R1) out of two residents sampled for ROM (Range of Motion), the facility failed to ensure that bilateral palm protectors were used to prevent a further decrease in ROM.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide routine dental services for two (R47 and R51) out of two sampled residents reviewed for dental services. Additionally, the facility failed to identify in the policy and procedure circumstances for when the loss or damage of dentures is the facility's responsibility.

Inspectors wroteBased on observation, record review, and interview, it was determined that the facility failed to adhere to a food preference for one (R53) out of two residents sampled for food investigation.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to develop policies and procedures for the monthly MRR (Medication Regimen Reviews) that included time frames for different steps in the MRR process.