August Healthcare at Wilmington

In the surveyor’s words

From the most serious findings on record at August Healthcare at Wilmington, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Nov 20, 2023

  Based on observations, record review, staff, Physician Assistant, Physician, Emergency Medical Service Responder, Adult Day Care staff nurse, and Pharmacist Consultant interviews, the facility failed to prevent a significant medication error when Medication Aide #1 administered Resident #1 medications prescribed to Resident #3 to include Clonazepam (a medication to treat anxiety classified as benzodiazepine) 1 milligram (mg) and Buprenorphine HCI-Naloxone (a medication to treat opioid addiction) 8mg/2 mg causing Resident #1 to become unresponsive. […]

• Actual harm, isolatedF760Nov 8, 2022

  Based on record review and staff, Nurse Practitioner, Physician Assistant and Physician interviews, the facility failed to accurately administer medications when Resident #1 was administered medications prescribed to Resident #6 to include [MEDICATION(S)] (a blood pressure medication) 50 milligrams (mg) extended release and [MEDICATION(S)] (an antianxiety medication) 1 mg resulting in Resident #1 having increased sleepiness and a decrease in blood pressure which required her to be sent to the emergency room for further evaluation for 1 of 2 residents reviewed for medication errors. Findings included: Resident #1 was admitted to the facility on [DATE] with admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF727Jan 20, 2023

  Based on record review and staff interviews the facility failed to have a registered nurse (RN) scheduled for 8 consecutive hours a day for 2 of 92 days (09/02/22 and 09/12/22) reviewed for nurse staffing. This deficient practice had the potential to affect all facility residents. Findings Included: Review of the facility's computerized payroll data from 07/01/22 through 09/30/22 revealed there was no registered nurse (RN) in the building on 9/2/22 and 9/12/22. An interview was conducted with the Nursing Scheduler on 1/10/23 at 2:10 PM. The Nursing Scheduler stated that she was put in charge of scheduling after the former Director of Nursing (DON) left in October 2022. […]

• No harm, potential for more than minimal, widespreadF880Jan 20, 2023

  Based on staff interviews the facility failed to establish a water management program for Legionella and other opportunistic waterborne pathogens. This had the potential to affect all facility residents. The findings included: In an interview with the Administrator on 01/11/23 at 10:40 AM he stated the facility did not have a water management program for Legionella or other waterborne pathogens. In an interview with the Maintenance Director on 01/11/23 at 1:30 PM he stated the facility did not have a water management program for Legionella or other opportunistic waterborne pathogens but the new company who bought the facility was sending in an outside contractor who would routinely check the water for Legionella and other pathogens. […]

• No harm, potential for more than minimal, patternF578Jul 17, 2026

  Based on record review, and staff, Physician Assistant (PA) and Physician interviews, the facility failed to have a system in place to inform and provide written information to the residents/representatives pertaining to their right to accept or refuse medical/surgical treatment and to formulate an advanced directive (a form that indicates a resident's wish and what action to take for their health if the residents were no longer able to make their own decision) for 15 of 22 sampled residents (Resident #1, #21, #71, #80, #105, #126, #5, #11 #20, #55, #14, #17, #7, #10, and #43.) Findings included: A review of the facility Advanced Directives Policy dated 11/02/22 indicated that: Code status (an intervention if a resident's heart stops beating) shall be discussed with every resident or the… […]