Wilmington Nursing & Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, it was determined that for one (R1) out of three residents reviewed for injuries, the facility failed to ensure that R1 received adequate care and treatment that met professional standards. R1, a cognitively impaired and dependent resident, was observed by a staff member with a visible head injury on 4/22/26 at approximately 6:00 AM and failed to inform the nursing staff at that time. The nurses were informed of the injury on 4/22/26 at approximately 8:30 AM, but failed to appropriately assess and provide care and treatment, including neurological checks. Each of the following shifts failed to identify and assess the injury, including failing to initiate neurological checks. [...]

Inspectors wroteBased on interview, record review, and review of other documentation as indicated, it was determined that for one (R11) out of four residents sampled for medication administration review, the facility failed to ensure that R11 was free from significant medication errors as evidenced by failing to check and monitor R11's blood sugars before meals, failing to administer ordered insulin and heparin injections. The facility's multiple failures to administer critical medications had the potential to cause a serious adverse outcome or death to R11. Due to the failures, an Immediate Jeopardy (IJ) was called on 5/8/26 at 1:24 PM. The IJ was abated on 5/9/26 at 11:59 PM.

Inspectors wroteBased on interview and review of clinical and facility records, it was determined that for two (R13 and R16) out of seven residents reviewed for abuse, the facility failed to ensure each resident remained free from physical and emotional abuse. On the morning of [DATE], R13 was physically and emotionally abused by a staff person, resulting in dehumanization, a psychosocial harm. On [DATE], R16 was physically abused by another resident (R17) in the locked dementia unit.

Inspectors wroteBased on interview and record review, it was determined that for three (R11, R13 and R26) out of eight residents reviewed for activities of daily living (ADLs), the facility failed to provide necessary services for personal hygiene care of dependent residents. R13, who had a perineal wound, returned from dialysis incontinent of bowel and requested to be changed. As a result of R13's toileting hygiene care request being deferred by staff until after dinner, R13 sat in a soiled incontinence brief for an additional two hours, resulting in dehumanization, a psychosocial harm. R26 was left soiled for four hours after requesting staff assistance. In addition, the facility failed to ensure that R11, a dependent resident, received the necessary services to maintain grooming and personal hygiene.

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that for one (R2) out of three residents sampled for accidents, the facility failed to ensure that R2 received adequate supervision and assistive devices to prevent accidents to the extent possible.

Inspectors wroteBased on record review, interview, and review of other facility documentation, it was determined for four (R1, R18, R27 and R28) out of five residents sampled for reporting of injuries, injuries of unknown origin, abuse and activities of daily living, the facility failed to ensure that all injuries, including injuries of unknown source were reported to the State Survey Agency within the guidelines. R1, a dependent resident was observed with visible head injury on 4/22/26 at 6:00 AM and was not reported to the State Survey Agency until 4/23/26 at 8:30 AM, more than 26 hours later. For R18, R27, and R28, the facility failed to report incidents of abuse and alleged neglect and to submit a follow-up report within the required timeframe.

Inspectors wroteBased on record review and interview, it was determined that for two (R11 and R26) out of eight residents reviewed for activities of daily living, the facility failed to ensure that the residents were treated with dignity. For R11, the facility failed to promote respect and dignity when he was found lying in bed on top of a plastic trash bag wearing two incontinence briefs. R26 was left unchanged and soiled after requesting assistance from staff.

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to ensure that one (R10) of 31 sampled residents, was given the right to self-determination when the resident was not provided an early lunch tray or a bagged lunch prior to his afternoon neurosurgeon appointment until the surveyor intervened.

Inspectors wroteBased on interview and record review, it was determined that for one (R9) out of four residents reviewed for change in condition, the facility failed to ensure that the physician was immediately consulted when R9's stat chest x-ray report revealed significant results.

Inspectors wroteBased on observation, interview and record review, it was determined that for two (R4 and R13) out of 27 sampled residents, the facility failed to respect each residents' right to personal privacy and confidentiality of personal care.

Inspectors wroteBased on interview and record review, it was determined that for one (R26) out of eight residents reviewed for activities of daily living, the facility failed to have evidence of a thorough investigation of a neglect allegation when R26 complained to staff that she had been left incontinent of feces for four hours after requesting assistance.

Inspectors wroteBased on observations, interviews and record reviews, it was determined that in one (R10) out of 31 sampled residents, the facility failed to develop a person centered care plan to address an identified need when R10 refused to wear his neck brace when out of bed.

Inspectors wroteBased on record review, interview and observation, it was determined that for one (R10) out of five residents sampled for resident records, the facility lacked evidence that oxygen therapy was administered as stated in the care plan and as ordered by the provider.

Inspectors wroteBased on observation, interview and record review, it was determined that for three (R14, R15 and R24) out of three residents sampled for medication storage, the facility failed to ensure each resident's medications were safely stored in a secured area and under direct observation of authorized staff. Additionally, the facility failed to properly dispose of each residents' expired medications.

Inspectors wroteBased on interview, record review, and review of other facility documentation, it was determined that for one (R11) out of 31 sampled residents, the facility failed to provide laboratory services to R11 when lab work ordered was not followed up after a failed specimen collection. In addition, the facility failed to ensure that a stat (at once) ordered lab draw result was reported to the physician in a timely manner.

Inspectors wroteBased on interview, record review and review of other facility documentation, it was determined that for one (R9) out of four residents reviewed for change in condition, the facility failed to ensure that a stat (at once) ordered chest x-ray was completed until 31 hours after it was ordered. In addition, the facility failed to ensure that R9's STAT chest x-ray result was reported to the physician in a timely manner.

Inspectors wroteBased on interviews and record reviews, it was determined that for one (R11) out of 4 residents reviewed for nutrition, the facility failed to maintain clinical records that meet professional standards of practice when R11's missing nutrition assessments were completed and signed by another Registered Dietitian on 5/5/26, one month after R11 was discharged from the facility on 3/26/26.

Inspectors wroteBased on interview and review of facility documents, it was determined that the facility failed to identify and correct R11's significant medication errors involving blood sugar checks, heparin and insulin injections.

Inspectors wroteBased on observations, interviews and review of records and the facility's policy and procedure, it was determined that for two (R29 and R30) out of 31 residents sampled during the survey, the facility failed to ensure infection control and prevention practices were followed.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure residents' rights to a dignified existence and self-determination when the facility failed to develop a system that notified residents of the daily menu.

Inspectors wroteBased on observation, interview, and record review, it was determined that for two (R150 and R35) out of five residents reviewed for infection control, the facility failed to initiate and maintain Enhanced Barrier Precautions (EBP) for contact with a resident with wounds and an indwelling medical device and failed to use appropriate disinfection practices. Also, the facility failed to prevent the risk of exposure to infectious and communicable diseases by not safely disposing a full sharps container.

Inspectors wroteBased on observation and interview, it was determined that for two (R11 and R62) out of 38 sampled residents, the facility failed to provide dignity and respect when facility staff called R11 and R62 feeders.

Inspectors wroteBased on observation, interview, and record review, it was determined that for one (R150) out of one resident reviewed for admission orders, the facility failed to ensure wound treatment orders were entered.

Inspectors wroteBased on observation, interview and record review, it was determined that for one (R16) out of one resident reviewed for dental services, the facility failed to accurately code R16's dental assessments for two MDS (Minimum Data Sets) review periods.

Inspectors wroteBased on record review and interview, it was determined that for one (R10) out of two residents reviewed for PASARR review, the facility failed to refer the resident for a PASSAR screening following a newly evident condition and qualifying medications.

Inspectors wroteBased on observation, interview and record review, it was determined that for one (R11) out of three sampled residents reviewed for ADLs (Activities of Daily Living), the facility failed to ensure each dependent resident received the necessary services to promote adequate nutrition.

Inspectors wroteBased on observation, interview and record review, it was determined that for one (R54) out of one resident reviewed for activities, the facility failed to provide an ongoing person-centered activity program for R54, who chooses to remain in her room all day.

Inspectors wroteBased on observation, interview and record review, it was determined that for one (R54) out of three residents reviewed for pressure ulcers, the facility failed to ensure that R54's low air loss mattress device was plugged in, turned on and functioning as a preventative intervention and per an active physician order.

Inspectors wroteBased on record review and interview, it was determined that for one (R149) out of nine residents reviewed for activities of daily living the facility failed to ensure documentation regarding urostomy and pelvic drain output was recorded as ordered.

Inspectors wroteBased on observation, interview and record review, it was determined that for two (R11 and R143) out of three sampled residents reviewed for nutrition, the facility failed to maintain acceptable parameters of nutrition and/or hydration.

Inspectors wroteBased on record review and interview, it was determined that for one (R1) out of one resident reviewed for dialysis, the facility failed to provide dialysis related care and services to meet the needs of the resident when pre-dialysis information was not completed on the dialysis communication form. Additionally, some dialysis communication forms were absent from the medical record.

Inspectors wroteBased on record review and interview it was determined that for one (R6) out of five residents reviewed for unnecessary medication review the facility failed to act upon a recommendation documented in the residents MRR.

Inspectors wroteBased on record review and interview, it was determined that for one (R149) out of one resident reviewed for change in condition, the facility failed to ensure ordered labs were completed timely.

Inspectors wroteBased on observation, interview and record review, it was determined that for one (R16) out of one resident reviewed for dental services, the facility failed to promptly provide routine and emergency dental care for R16 when he was recommended for follow up visits to restore his cavities and extract his extensively decayed root tips after his dental exam on 3/23/25.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that information informing residents of how to formally complain to the State Agency was displayed.

Inspectors wroteBased on observation, interview and review of clinical record and other documentation as indicated, it was determined that for three (R26, R105, R228 and R533) out five residents sampled for pressure ulcer, the facility failed to provide the necessary treatment and services consistent with professional standards of practice to promote healing and prevent new ulcers from developing. For R26, the facility failed to initiate and implement a sacral pressure ulcer care plan with appropriate interventions and hospice involvement and appropriately Stage her sacral pressure ulcer that started as MASD. As a result of multiple failures, R26 was harmed. For R105, R228 and R533, the facility failed to provide pressure ulcer wound care as ordered. In addition, the facility failed to complete weekly skin audits.

Inspectors wroteBased on interview and review of clinical record and other documentation as indicated, it was determined that for one (R116) out of two residents sampled for hospitalization, the facility failed to ensure that R116 was free from a significant medication error. R116 was prescribed and administered Metformin and Ibuprofen at 8:00 AM every day from 9/10/24 through 9/15/24 despite two pharmacy warnings. In the setting of poor oral intake and the facility initiating hypodermoclysis during this timeframe, R116's creatinine increased from 0.8 baseline to 4.2 and BUN increased from 23 to 87 prior to being sent emergently to the hospital, requiring treatment with intravenous fluids and the discontinuation of the Ibuprofen. R116 was harmed.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed store, prepare, distribute, and serve food in accordance with professional standards for food service safety.

Inspectors wroteBased on observation, interview, and record review, it was determined that for six (R26, R81, R89, R103, R326 and R328) out of 46 residents reviewed for care plans, the facility failed to develop and implement a comprehensive person-centered care plans for each resident. For R81, R89, R103 and R328, the facility failed to develop care plans based on assessment to restore and maintain their bladder and bladder continence to the extent possible. For R326, the facility failed to develop a person-centered care plan for R326 despite a high fall risk assessment. For R26, the facility failed to develop a pressure ulcer care plan.

Inspectors wroteBased on interview and record review, it was determined that for one (R116) out of seven residents sampled for incontinence and one (R26) out of one resident sampled for hospice, the facility failed to review and revise each residents' care plan.

Inspectors wroteBased on observations, interviews, and record reviews, it was determined that for five (R81, R89, R103, R116 and R328) out of seven residents reviewed for bowel and bladder assessments, the facility failed to conduct bowel and bladder assessments to develop an individualized care plan to restore and maintain their bladder and bladder continence to extent possible.

Inspectors wroteBased on interview and review of the clinical record and other documentation as indicated, it was determined that for one (R26) out of one resident reviewed for hospice, the facility failed to ensure that R26 received hospice care and services as per the written agreement with the Hospice Provider. Specifically in reference to the deficiency cited at Severity Level 3, at F686, the facility failed to notify and collaborate with the Hospice Provider on developing and implementing a sacral pressure ulcer plan of care with interventions to meet the resident's needs. In addition, the facility failed to update the Hospice Provider that R26's eight medications were discontinued in January 2024; and ensure that current Hospice documentation was present and readily accessible in R26's facility clinical record.

Inspectors wroteBased on observations, interviews and record reviews, it was determined that for four ( R533, R105, R12 and R26) out of four residents reviewed for infection control, the facility failed to establish and maintain an infection control program using enhanced barrier precautions. R12, R105 and R533 had indwelling feeding tubes which met the criteria for Enhanced Barrier Precautions (EBP).

Inspectors wroteBased on record review and interview, it was determined that for four (R9, R30, R53 and R76) out of five residents sampled for Covid-19 vaccinations, the facility failed to provide education regarding the benefits and potential side effects of Covid-19 immunizations to each resident or the resident's representative and then offer the immunization.

Inspectors wroteBased on record review and interview, it was determined for one (R118) out of the survey sample reviewed for planning and implementing care, the facility failed to provide R118 the right to be informed of and participate in her treatment.

Inspectors wroteBased on interview and record review, it was determined that one (R76) out of four residents reviewed for resident rights, the facility failed to identify and facilitate the resident's self-determination through support of resident choice with respect to his scheduled shower times.

Inspectors wroteBased on interview and record review, it was determined that for one (R26) out of five residents reviewed for pressure ulcers, the facility failed to accurately reflect R26's medical status in the annual MDS assessment.

Inspectors wrote2. According to the Mayo Clinic, May 2022, Orthostatic hypotension is a form of low blood pressure that happens when standing after sitting or lying down. Orthostatic hypotension can cause dizziness or lightheadedness and possibly fainting. A care provider might review medical history, medications and symptoms and conduct a physical exam to help diagnose the condition. A provider also might recommend orthostatic blood pressure monitoring. This involves measuring blood pressure while sitting and standing. A drop of 20 millimeters of mercury (mm Hg) in the top number (systolic blood pressure) within 2 to 5 minutes of standing is a sign of orthostatic hypotension. A drop of 10 mm Hg in the bottom number (diastolic blood pressure) within 2 to 5 minutes of standing also indicates orthostatic hypotension. Review of R127's clinical record revealed: [...]

Inspectors wroteBased on observations, interviews, and record review, it was determined that for one (R105) out of two residents reviewed for mobility, the facility failed to provide assistance to maintain or improve mobility. For R105, the facility failed to ensure the resident's therapy devices were applied per physician orders.

Inspectors wroteBased on observation, interview, record review, it was determined that for one (R64) out of two residents reviewed for accidents, the facility failed to ensure that R64 received supervision to prevent accidents.

Inspectors wroteBased on interviews and record review, it was determined that for one (R83) out of four residents reviewed for nutrition, the facility failed to maintain acceptable parameters of nutrition.

Inspectors wroteBased on observation and interview, it was determined that for one (R105) out of four residents reviewed for tube feeding, the facility failed to ensure that the standard of care for the proper labeling and dating of tube feeding bottles was followed. A review of R105's clinical record revealed: 4/30/24 - R105 was admitted to the facility with a diagnosis of a stroke, and difficulty swallowing food and liquids. 9/19/24 10:40 AM - During an observation, the tube feeding bottle was being administered at R105's bedside. No date was written on the tube feeding bottle. 9/20/24 11:30 AM - During an observation, the tube feeding bottle was administered at R105's bedside. No date was written on the tube feeding bottle. 09/20/24 11:54 AM - During an interview, E24 (RN) confirmed that the tube feed bottle had no date written on it.

Inspectors wroteBased on observation, interview and record review, it was determined that for one (R3) out of three sampled residents reviewed for respiratory care, the facility failed to ensure that R3 was provided respiratory care consistent with her physician orders and comprehensive person-centered care plan.

Inspectors wroteBased on observation, interview and record review, it was determined that for one (R26) out of five residents reviewed for pressure ulcers, the facility failed to ensure R26's pain management during wound care was consistent with her care plan and professional standards of practice.

Inspectors wroteBased on observation, review of facility documentation and staff interviews, it was determined that the facility failed to post the required federal staffing information in a conspicuous area that was readily accessible to residents and visitors.

Inspectors wroteBased on interview and record review, it was determined that for one (R116) out of two residents reviewed for hospitalizations, the facility failed to monitor and hold R116's blood pressure medication based on physician ordered parameters.

Inspectors wroteBased on interview and record review, it was determined that for one (R116) out of three residents reviewed for nutrition, the facility failed to order and provide an Ensure drink based on the admission nutrition assessment and resident preference.

Inspectors wroteBased on record review and interview, it was determined that for three (R9, R53 and R76) out of five residents sampled for influenza and pneumococcal vaccinations, the facility failed to provide education regarding the benefits and potential side effects of either/both influenza and pneumococcal immunizations to each resident or the resident's representative and then offer the immunization.

Inspectors wroteBased on observations and interview, the facility failed to provide a safe, sanitary, environment for residents, staff and the public.

Inspectors wrote3. Review of R6's clinical record revealed the following: A facility policy titled Fall Management Program effective 1/29/24 documented, .A fall is defined .unintentional change in elevation coming to rest on the ground or onto the next lower surface .Procedure .Prevention 1. A Fall Risk Scoring Tool will be completed .and as needed for change in condition . 8/6/24 11:55 AM - A nurse progress note documented that R6 was noted on the floor on her knees, and her head was over the bath tub in her bathroom. 8/7/24 - A facility Fall Risk Scoring Tool for R6 with a score of 7 (low risk) was completed by E28 (LPN). 8/11/24 3:51 AM - The same Fall Risk Scoring Tool for R6 was struck out for the reason: data entry error. 9/30/24 10:30 AM - In an interview, E2 (DON) stated that the Fall Risk Scoring Tool for [R6] completed by [E28] on 8/7/24 was not accurate. [...]

Inspectors wrotePost IDR [DATE] revision Based on observation, interview and review of clinical records and other documentation as indicated, it was determined that for two (R1 and R2) out of four residents reviewed for follow-up appointments, the facility failed to ensure that the correct resident (R1) was sent to a cardiology appointment on [DATE]. R2, a newly admitted cognitively impaired resident, was sent with R1's medical paperwork and accompanied by a facility aide, who did not know the resident. At the appointment, R2 was slumped in a wheelchair with altered mental status and the facility aide did not know the resident's baseline. 911 was called and R2 was emergently sent to the emergency room (ER) with R1's medical paperwork. In the ER, R2 was initially registered under R1's name until it was brought to the ER's attention. [...]

Inspectors wroteBased on interview and review of the clinical record and additional documentation as indicated, the facility failed to notify and update C5 (Optum NP) of changes to R3 after her fall on 4/5/24 to determine if further interventions were needed.

Inspectors wroteF686 - Based on observation, interviews, and record review, it was determined that for one (R10) out of one resident reviewed for the treatment/services to prevent/heal pressures, the facility failed to initiate treatment and monitoring when R10 was readmitted on [DATE] with a sacral pressure ulcer.

Inspectors wroteBased on interview and review of the clinical record and other documentation as indicated, it was determined that for one (R2) out of one resident reviewed for physician ordered bladder scanning, the facility failed to ensure that the resident, who was incontinent of bladder, received appropriate treatment and services to prevent an urinary tract infection.

Inspectors wroteBased on a review of the facility assessment, emails and interview, it was determined that the facility failed to update the facility assessment to include all personnel classifications which provide services to facility residents.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to update the facility Governing Body documents to remove the name of a governing body member who was no longer employed by the facility .

Inspectors wroteBased on observations, interviews and reviews of clinical records and other facility documentation, it was determined that the facility failed to ensure there were sufficient nursing staff to administer critical medications to meet the needs of the residents during the 7:00 AM to 3:00 PM shift on Friday, 7/21/23. For three residents (R22, R51 and R630) on the Dover Unit that were ordered Humalog insulin to be administered with breakfast (scheduled at 7:35 AM), revealed the following: - R22 was never administered insulin with breakfast. - R51 was administered insulin at 10:48 AM and 10:50 AM, approximately 3.5 hours later. - R630 was administered insulin at 9:56 AM and 9:57 AM, approximately 2.5 hours later. For one resident (R631) on the Heritage Unit that was ordered Humalog insulin with breakfast revealed that R631 never received the ordered insulin. [...]

Inspectors wroteBased on observations, interviews, and reviews of clinical records and other documentation as indicated, it was determined that for four (R22, R51, R630 and R631) out of seven residents reviewed in three hallways, the facility failed to ensure these residents received timely administration of insulin due to no staff being available to provide the medication. The facility's failure placed the residents at risk for a serious adverse outcome, hypoglycemia and hyperglycemia. Due to this failure, an Immediate Jeopardy (IJ) was called at 3:40 PM on 7/21/23. The IJ was abated on 7/24/23 at 9:00 AM. Additionally, R80 was not administered physician ordered insulin on 7/16/23 at 6:00 AM due to no staff being available on the night shift.

Inspectors wroteBased on interviews, record review and review of other documentation as indicated, it was determined that for one (R23) out of three residents sampled for falls, the facility failed to ensure that readmission physician orders for two anti-seizure medications were accurately transcribed into the electronic health record for R23's immediate care of her seizure disorder. From 9/8/23 through 9/20/23, R23 did not receive 24 doses of Vimpat and was administered five (5) incorrect doses of Keppra. On 9/29/23, R23 had a seizure and fell during a therapy ambulation session and was transferred to the hospital, evaluated and treated with anti-seizure medication. Due to the facility's failure, an Immediate Jeopardy (IJ) was called at 3:20 PM on 10/26/23. The IJ was abated on 10/27/23 at 5:00 PM.

Inspectors wroteBased on observation, interview and record review, it was determined that for one out of one resident (R49) reviewed for respiratory/tracheostomy care, the facility failed to provide tracheal suctioning consistent with professional standards of practice.

Inspectors wroteBased on observation, interview, record review and review of other documentation, it was determined that for three (R140, R38 and R36) out of four residents reviewed for pressure ulcers, the facility failed to ensure that residents at risk for pressure ulcers, or those with pressure ulcers received the care and services to promote healing and to prevent new pressure ulcers from occurring. For R140, the facility lacked evidence of a turning and repositioning intervention causing harm to the resident related to avoidable new unstageable and suspected deep tissue pressure ulcer development. In addition, for R140, the facility failed to identify and treat R140's pressure ulcers. For R38 the facility lacked evidence of physician ordered wound treatments and interventions being implemented causing harm to the resident related to new avoidable pressure ulcer development. [...]

Inspectors wroteBased on observations, interviews and reviews of clinical records, facility and other documentation as indicated, it was determined that for three (R86, R135 and R137) out of three residents sampled for hydration, the facility failed to ensure the residents were offered, assisted and monitored for sufficient fluid intake to maintain proper hydration and health, which resulted in harm for all three residents where they required emergent treatment. For R86, the facility's failure to encourage and monitor the resident's fluid intake to ensure adequate hydration resulted in an emergent transfer and hospitalization requiring administration of four liters of intravenous (IV) fluids and treatment for a UTI (urinary tract infection). [...]

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to provide and store food in accordance with professional standards for food service safety.

Inspectors wroteBased on interview and record review of the facility's Infection Surveillance Monthly Report, it was determined that the facility failed to provide an ongoing system of surveillance designed to identify possible communicable diseases and infections.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to maintain required kitchen equipment to prepare food for residents were in safe working order.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to ensure that two (R75 and R579) out of 30 residents in the investigative sample were offered the opportunity to formulate an advance directive.

Inspectors wroteBased on interview and observation of four out of four units toured, it was determined that the facility failed to provide a safe, clean, and homelike environment.

Inspectors wrote2. Review of R129's clinical record revealed: 8/18/21 - R129 was admitted to the facility. 11/29/21 - A review of facility grievance log revealed that R129's responsible party filed a grievance related to R129's care. 7/27/23 - A review of R129's concern form from the grievance (11/29/21) revealed the facility lacked evidence of a response to the concern. An interview with E4 (Corporate Consultant) confirmed the facility lacked evidence of a response to the grievance. 7/27/23 2:45 PM - Findings reviewed with E1 (NHA) and E4 (RCD).

Inspectors wroteBased on record review and interview, it was determined that for three (R65, R71 and R141) out of five residents reviewed for care planning, the facility failed to review and revise their care plans to reflect individual identified needs. For R65 and R71 the facility failed to facilitate an interdisciplinary care plan. For R141, the facility failed to have the required interdisciplinary team members at the care plan conference

Inspectors wrote5. Review of 133's clinical record revealed: 4/8/21 - R133 was admitted to the facility with multiple diagnoses including heart failure. 4/15/21- A Physician's order was written for R133 to be weighed daily and to notify the physician if R133 had a weight gain of 3 pounds (lbs.) in 24 hours or 5 lbs. in 1 week. R133's weights: 4/19/21 - 199.8 lbs. 4/26/21 - 219.0 lbs. Weights were not obtained on R133 for five (5) consecutive days, from 4/20/21 thru 4/25/21. R133 experienced a twenty-pound (20) weight gain during the week of 4/19/21 - 4/26/21. 6. Review of 138's clinical record revealed: 5/31/21 - R138 was admitted to the facility with diagnoses including cardiac disease and high blood pressure. 5/31/21 - R138's care plan for heart disease had an intervention that stated to call the physician if R138's heart rate was less than 50. [...]

Inspectors wroteBased on observation, record review and interview, it was determined that for one (R86) out ___ resident reviewed for bowel and bladder, the facility failed to ensure that R86 received the care and services necessary to restore or maintain bladder function.

Inspectors wrote2. Review of R134's clinical record revealed: 8/4/21 - R134 was admitted to the facility with a diagnosis of chronic pain. 8/4/21 - R134 was ordered oxycodone (a pain medication). 8/4/21 - R134's admission assessment documented that she had frequent pain, and at the time of the assessment R138 expressed that her pain level was an eight out of ten. Review of R 134's medication administration record revealed: 8/4/21 8:30 PM - R134 was administered pain medication for a pain level of nine out of ten. The post pain medication assessment was documented as E (effective) and did not include a numerical score. 8/5/21 - R134 was administered pain medication at 1:25 AM for a pain level of six out of ten, 10:10 AM for a pain level of five out of ten and only documented as effective. [...]

Inspectors wrote3. Review of R101's clinical record revealed: Cross refer F758 8/3/22 - R101 was admitted to the facility. 9/8/22 9:34 AM - A review of the MRR revealed a recommendation to consider a dose reduction or discontinue to Risperidone 0.75mg by mouth at bedtime. 7/27/23 11:00 AM - A review of the Physicians order sheet for R101 revealed that the above recommendation for Risperidone had not been acknowledged. 4. Review of R129's clinical record revealed: 8/18/21 - R129 was admitted to the facility. 4/6/22 - A review of the MRR revealed a recommendation to reevaluate the use of triple antidepressant therapy and consider dose reduction or discontinue one of the medications: Sertaline 50 mg, Trazadone 25 mg, and Remeron 7.5 mg. The MRR was not signed by the Physician. 5. Review of R179's clinical record revealed: 2/18/21 - R179 was admitted to the facility. [...]

Inspectors wroteBased on a review of facility documentation, it was determined that the facility failed maintain a quality assessment and assurance committee consisting of the required minimum members.

Inspectors wroteBased on interview and review of facility documentation, 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 ensure E15, E74, and E76 had training on dementia management, care of the cognitively impaired, abuse and neglect.

Inspectors wroteBased on observations and interview, it was determined that for three (R4, R22 and R43) out of 43 residents sampled and general observations on one of four units, the facility failed to ensure that each resident was treated with respect and dignity.

Inspectors wroteBased on record review and interview it was determined that for one (R113) out of one resident reviewed for notification of change in condition the facility failed to consult with the resident's physician in a timely manner.

Inspectors wroteBased on interview and record review, it was determined that for two (R3 and R179) out of four residents reviewed for PASARR, the facility failed ensure that a referral for a PASARR screening was completed following a new diagnosis of psychotic disorder which was not listed on the previous PASARR.

Inspectors wroteBased on record review and interview it was determined that for four (R87, R129, R281 and R101) out of twenty-seven residents in the investigative sample, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan.

Inspectors wrote2. Review of R79's clinical record revealed: 1/21/23 - R79 was admitted to the facility with a diagnosis of Dementia and Chronic kidney disease. 1/23/23 - Review of R79's care plan for ADL self-care deficit related to cognitive deficits and impaired mobility revised on 6/29/23 documented: 1. Will receive assistance necessary to meet ADL (Activity of Daily Living) needs. 2. Will be clean, well dressed, and well-groomed daily to promote dignity and psychosocial wellbeing. 3. Assist with daily hygiene, grooming, oral care and eating as needed. 4/29/23 - A quarterly MDS Assessment documented, that R79 was severly cognitively impaired and required extensive assist with one-person physical assist for bed mobility, transfers, eating, toileting, and personal hygiene. 6/8/23 - Review of R79's care plan for risk for falls revised 6/29/23 documented the use of non-skid socks while out of bed. [...]

Inspectors wrote2. Review of R65's clinical record revealed: 11/29/20 - R65 was admitted to the facility. 3/30/23 - Due to a complaint of a decrease in hearing, R65 completed a hearing assessment that recommended a follow-up with an ENT (Ears, Nose, and Throat Doctor). 5/22/23 - During R65's ENT follow-up, R65 was found to have cerumen (earwax) accumulation in the left ear with instructions for treatment stating, debridement and treatment of ear drops Acetasol HC both ears 3 drops BID (twice a day) x 14 days. 6/9/23 - R65's quarterly MDS (Minimum Data Set) assessment evaluated the resident to have adequate hearing. 7/13/23 11:05 AM - An interview with R65 and FM2 revealed that the M.D. (Medical Director) recommended a hearing evaluation for R65 who is hard of hearing. FM2 said I have to speak loudly and clearly to [my] mom because she can hardly hear . [...]

Inspectors wroteBased on record review, observation, and interview, it was determined that for two (R16 and R36) of three residents reviewed for range of motion (ROM), the facility failed to ensure that residents received the care and/or treatment to maintain or improve ROM.

Inspectors wroteBased on record review, interview, and review of facility documentation, it was determined that for two (R26 and R91) out of fifteen(15) residents sampled for accidents, the facility failed to ensure that R26 and R91received adequate supervision and assistance to prevent an accidents.

Inspectors wroteBased on interview, observation and record review, it was determined that for one (R49) out of one resident sampled for tube feeding, the facility failed to ensure that the tube feeding formula and water flush were labeled with the name, date, time, and rate of infusion on 10/22/23.

Inspectors wroteBased on record review and interview, it was determined that for one (R3) out of seven residents reviewed for unnecessary medications, the facility failed to monitor side effects of a psychoactive medication.

Inspectors wroteBased on observations and interviews, it was determined that for two (R8 and R21) out of two residents reviewed for menus, the facility failed to follow the menu items listed on the menu.

Inspectors wroteBased on observation, interview and review of facility documentation, it was determined that for one (R100) out of one residents sampled for preferences, the facility failed to provide the resident's food preference for breakfast.

Inspectors wroteBased on record review, facility policy review, and interview, 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 prior to assuming the role of the IP.

Inspectors wroteBased on interview and observation, it was determined that the facility failed to ensure adequate outside ventilation by means of windows, or mechanical ventilation, or a combination of the two in the Arcadia unit.

Inspectors wroteBased on interview and review of facility documentation, it was determined that the facility failed to ensure that the required training for new and existing staff was completed for one (E53) out of five staff for the Facility Assessment.

Inspectors wroteBased on interview and review of facility documentation, it was determined that the facility failed to ensure that the required training for Resident Rights was completed for one (R53) out of five staff.

Inspectors wroteBased on interview and review of facility documentation, it was determined that the facility failed to ensure that the required training on abuse, neglect, exploitation and misappropriation of resident property was completed for three (E32, E53 and E54) out of 11 randomly sampled staff members.

Inspectors wroteBased on interview and review of facility documentation, it was determined that the facility failed to ensure that the required training for QAPI (Quality Assurance and Performance Improvement) was completed for one (R53) out of five staff.

Inspectors wroteBased on interview and review of facility documentation, it was determined that the facility failed to ensure that the required training for Compliance and Ethics was completed for one (R53) out of five staff.

Inspectors wroteBased on interview and review of facility documentation, it was determined that the facility failed to ensure that the required training for Behavioral Health Training was completed for one (R53) out of five staff.