Care One at Wilmington

In the surveyor’s words

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

• Actual harm, isolatedF656Jun 17, 2021

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was a risk for falls and required two staff members to provide assistance with transfers, the Facility failed to ensure staff consistently implemented interventions from his/her comprehensive plan of care, when on 05/20/21, Certified Nurse Aide (CNA) # 1 transferred Resident #1 into his/her wheelchair without the assistance of another staff member, Resident #1 hit his/her right hip on the side of the wheelchair, causing him/her severe pain, and he/she was transferred to the Hospital Emergency Department where he/she was diagnosed with a right proximal femur (hip) fracture requiring surgical repair. […]

• Actual harm, isolatedF689Jun 17, 2021

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed as requiring two staff members to provide physical assistance to safety transfer, the Facility failed to ensure his/her safety was maintained to prevent an incident/accident resulting in an injury. On 05/20/21, Certified Nurse Aide (CNA) # 1 assisted Resident #1 with a transfer into his/her wheelchair without the assistance of another staff member, Resident #1 hit his/her right hip on the side of the wheelchair, causing him/her severe pain, and he/she was transferred to the Hospital Emergency Department, where he/she was diagnosed with a right proximal femur (hip) fracture requiring surgical repair. […]

• No harm, potential for more than minimal, isolatedF684Jul 31, 2025

  Based on observation, record review and interview the facility failed for one Resident (#2) out of a total sample of 21 residents to ensure that following a skin tear, care was provided in accordance with professional standards of practice. Specifically, the facility failed to a.) obtain an order for treatment of a new skin tear and b.) failed to assess the skin tear on a weekly skin assessment.Findings include:The facility policy titled Skin Tears- Abrasions and Minor Breaks, Care of, dated as revised September 2013, indicated: Purpose: The purpose of this procedure is to guide the prevention and treatment of abrasions, skin tears, and minor breaks in the skin. Preparation:Obtain a physician's order as needed. […]

• No harm, potential for more than minimal, isolatedF677Jun 14, 2023

  Based on observations, record review and interviews, the facility failed to provide assistance with meals as needed for 1 Resident (#268) out of a total sample of 24 residents. Findings include: Review of the facility policy titled, Assistance with Meals, dated March 2022, indicated the following: *Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity. Findings include: Resident #268 was admitted to the facility in June 2023 with diagnoses including dysphagia. During an observation on 6/13/23 at 8:41 A.M., Resident #268 was observed eating breakfast while lying in bed in his/her room with no staff present to assist or supervise as needed. […]

• No harm, potential for more than minimal, isolatedF695Jun 14, 2023

  Based on observation, record review and interviews, the facility failed to obtain a physician order for the use of a CPAP machine (a machine for Continuous Positive Airway Pressure to treat sleep apnea) for 1 Resident (#271) with a diagnosis of sleep apnea out of a total sample of 24 residents. Findings include: Review of the policy titled, CO CPAP/BiPAP Support, dated 6/7/18, indicated the following: *Purpose: 1. To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. 2. To improve arterial oxygenation (PaO2) in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. 3. To promote resident comfort and safety. *Preparation: 2. […]