Every finding on record at Center at Eden Hill, LLC

Based on observation, interview, and record review, it was determined that for one (R63) out of six residents reviewed for infection control, the facility failed to use appropriate infection control practices. For R63 when cleaning/disinfecting reusable resident medical equipment. Findings include: Review of the facility's policy and procedure titled, C. diff Infection Precautions, last updated 4/15/26, documented, . equipment should be cleaned and disinfected according to facility policy using an appropriate disinfectant for C. diff .1. 4/17/26 - R63 was admitted to the facility.5/16/26 6:42 PM - A physician ordered to collect blood and stool to rule out Clostridioides difficile (C. difficile) for low-grade temperature for one day for R63.5/18/26 10:35 AM - A physician ordered diarrhea isolation precautions for R63 following three episodes of diarrhea. The order included 24-hour strict isolation with services provided in a single room, holding laxatives, notifying the physician, obtaining stool specimens, and monitoring each shift to rule out C. difficile. The preliminary diagnosis was acute infectious viral gastroenteritis. 5/18/26 5:18 PM - The stool test results for R63 were that C. difficile was detected.5/18/26 5:59 PM - A physician ordered strict contact transmission-based precautions for R63 due to C. difficile, requiring all care and services to be provided in the resident's room each shift through 6/2/26 at 11:59 PM. 5/19/26 12:05 PM - During a medication pass, E5 (LPN) and E6 (LPN orienting) revealed that a blood pressure was needed to determine if a medication was to be given to R63. E5 asked E6 to get the blood pressure for R63. An observation was made in which E6 took the vital-sign machine, which is used on all residents, donned appropriate PPE, and entered R63's room. E6 proceeded to take the blood pressure for R63, doffed the PPE, performed hand hygiene, put on clean gloves, and cleaned the vital sign machine and all equipment with a cleaning agent containing isopropyl alcohol. E6 returned the vital-sign machine to the hallway for use by other residents. During an interview, E5 stated that R63 is on contact precautions for confirmed C. difficile.5/19/26 3:01 PM - During an interview, E5 stated the shared vital sign machine should have been disinfected with bleach wipes after use for R63. E5 reported disposable equipment was available in R63's room and indicated there was no need for the shared vital sign machine to enter the room.

Based on observation, record review and interview it was determined that for one (R94) out of two residents reviewed for urinary tract infections the facility failed to ensure that a resident with a urinary catheter remained free of infection. Findings include: John Hopkins medical center guidelines regarding antibiotic stewardship for UTI indicated, Enterococcus [bacteria] can be a contaminant or colonizer, particularly in patients with urinary catheters or multiple organisms growing in urine culture. https://www.hopkinsmedicine.org/-/media/antimicrobial-stewardship/bacterial_uti_guidelines.pdf. 3/28/25 - The facility policy on Foley catheter care indicated, Foley catheter care will be provided routinely and as needed according to facility practice, infection control standards, and applicable clinical guidance .The drainage bag will be kept below the level of the bladder when feasible and will not be placed on the floor. Review of R94's clinical record revealed; 4/15/26 - R94 was admitted to the facility. 4/15/26 - A physician order was written for R94 to receive Foley catheter care each shift and as needed for foley catheter maintenance. 5/11/26 - A progress note in R94's clinical record written by E13 (NP) documented, Chief Complaint / Nature of Presenting Problem: altered mental status, back pain. Patient seen today resting in bed, noted with some confusion. Advised patient will order urinalysis culture and sensitivity. 5/12/26 - A progress note in R94's clinical record written by E13 (NP) documented, Urinalysis showed some markers of infection. Will send urine culture and empirically start on Vantin (antibiotic). 5/13/26 - A physician's order was written for R94 to receive Vantin an antibiotic for treatment of a UTI twice a day for seven days. 5/14/26 - Urinalysis culture and sensitivity test reported enterococcus faecalis (bacteria) in R94's urine in an amount that indicated an infection with a sensitivity to Penicillin. 5/15/26 - A physician's order was written for R94 to receive penicillin an antibiotic for treatment of a UTI four times a day for seven days. April 2025 - Review of R94's TAR lacked evidence that catheter care was completed the following shifts below: 4/15 night4/16 evening4/19 evening4/23 evening4/24 night4/29 night.May 2025 - Review of R94's TAR lacked evidence that catheter care was completed the following shifts below:5/2 evening5/4 night5/6 day5/6 evening5/9 evening5/9 night5/11 night5/18 night.5/19/26 11:19 AM - During a random observation R94's foley catheter bag was observed directly on the floor, privacy bag was askew allowing bag to be directly on the floor. Observation immediately confirmed by E12 (RN). 5/19/26 2:35 PM - During an interview E3 (ICP and ADON) confirmed that R94's foley catheter should not have been on the floor and that catheter care is to be completed as ordered. 5/22/26 3:40 PM -Findings were reviewed the exit conference with E1 (NHA) and E2 (DON).

Based on record review and interview it was determined that for one (R108) out of twenty-eight sampled residents the facility failed to create an individualized care plan to address R108's use of a specialized TLSO brace. Findings include:7/18/25 - R108 was admitted to the facility with multiple diagnoses including a broken bone in her back [lumbar]. 7/21/25 - Care plans were initiated for R108. Review of the care plans lacked evidence of a care plan created for R108's TLSO brace. 7/22/25 - An admission MDS assessment documented that R108 had fractures as active diagnoses and required partial moderate assistance with upper body dressing. 8/20/25 8:52 PM - A neurologist consultant appointment note in R108's clinical record documented, continue to wear brace, must be supporting of her lumbar spine. 8/25/25 - A physician's progress note in R108's clinical record documented, Patient had L1 compression fracture. Patient was evaluated at bedside, stating that she is feeling weak. She has a (TLSO) brace, seems to be very wide as it is going to her chest. Also, she is not strong enough to able to apply a very tightly, which may be impeding her healing of the fracture. July 2025 - POC documentation attested to application of the TLSO brace at all times. August 2025 - POC documentation attested to application of the TLSO brace at all times. 5/22/26 12:11 PM - During an interview E4 (CNA) reported that in general instruction about TLSO braces is through verbal report. 5/22/26 2:54 PM - During an interview E2 (DON) confirmed that the facility failed to develop a care plan related to R108's use of the TLSO brace and interventions for its application, positioning and tightness for desired outcome. 5/22/26 3:40 PM - Findings were reviewed at the exit conference with E1 (NHA) and E2 (DON).

Based on record review and interview it was determined that for one (R108) out of four residents reviewed for hospitalization the facility failed to ensure that the residents discharge medication orders were correctly transcribed. The incorrect transcription resulted in the administration of a decreased dosage of R108's antidepressant medication. Findings include: Review of R108's clinical record revealed:7/14/25 - 7/18/25 - R108 was hospitalized . Discharge instructions dated 7/18/25 directed that R108 continue prescribed medications, including fluoxetine 20 mg daily for depression. 7/18/25 - R108 was admitted to the facility with multiple diagnoses including depression. 7/19/25 - A physician's order was written for R108 to receive fluoxetine 10 mg daily for depression. The clinical record was unclear why the antidepressant medication dosage was reduced from the order on the discharge documentation. 7/22/25 - An admission MDS assessment documented that R108 had a diagnosis of depression and received antidepressant medication. 7/24/25 - An initial psychology visit note documented that R108 had mild depression. 7/26/25 - A care plan for depression was created for R108 with the intervention to administer medication according to physician's order. July 2025 - Review of R108's MAR revealed thirteen doses of fluoxetine 10 mg given. August 2025 - Review of R108's MAR revealed four doses of fluoxetine 10 mg given. 8/4/25 - A psychiatry progress note in R108's clinical record documented Depression/Anxiety. Change fluoxetine to 20 mg to target mood. 8/4/25 - A physician's order was written to increase R108's fluoxetine from 10 mg daily to 20 mg daily for depression. 8/4/25 - 4:11 PM - A progress note in R108's clinical record documented, Per daughter the patient is on 20 mg of [fluoxetine], records review noted a transcription error and daughter was made aware of this and attending physicians as well as Psych NP was notified and the medication was updated to the home does of 20 mg daily. 5/22/26 2:54 PM - E2 (DON) confirmed that the facility failed to correctly transcribe the initial order for R108's antidepressant medication resulting in seventeen undermedicated doses. 5/22/26 3:40 PM - Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on record review and interview it was determined that for one (R1) out of five residents sampled for medication review, the facility failed to ensure that R1 received medication with adequate monitoring. Findings include:Review of R1's clinical record revealed: 2/27/26 - R1 was admitted to the facility. 3/7/26 - A care plan documented that R1 had high blood pressure with the following interventions: administer medications per physician orders; assess for signs and symptoms of high blood pressure; and monitor blood pressure as indicated. 4/7/26 - A physician's order documented Losartan Potassium 25 mg give one tablet by mouth one time a day for hypertension: hold is systolic blood pressure (SBP) is less than 120 mmHg. 5/2026 - A review of the May MAR documented losartan potassium 25mg was administered on the following dates: 5/2/26 - BP 113/63. 5/10/26 - BP 111/68.5/11/26 - BP 107/62.5/15/26 - BP 108/72.5/17/26 - BP 110/60.5/18/26 - BP 110/65.5/19/26 1:31 PM - During an interview, E7 (LPN) stated that the expectation is to follow the physician's order and hold medication if the blood pressure does not fall within the parameters to give. E7 also stated if the resident's blood pressure medication was consistently being held it should be reported to the provider for reassessment. 5/19/26 3:18 PM - During an interview, E14 (LPN) stated the aforementioned blood pressure readings did not meet the parameters to administer the medication and confirmed per the MAR they were administered. 5/22/26 3:40 PM - Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on record review and interview it was determined that for two (R77 and R2) out of six residents reviewed for unnecessary medications the facility failed to ensure prompt pharmacy services were provided to newly admitted residents resulting in missed doses of medications. Findings include:3/28/24 - The facility policy for admissions documented that persons will be accepted for admission on ly if the services and or care provided can reasonably be provided. 1. Review of R77s' clinical record revealed: 4/4/26 8:00 PM - R77 was admitted to the facility with multiple diagnoses including anxiety. 4/4/26 - A physician's order was written for R77 to receive clonazepam twice daily for anxiety. 4/4/26 11:24 PM - A progress note in R77's clinical record documented that the resident was not given their ordered clonazepam because staff was waiting for pharmacy to clear order. 4/5/26 8:07 AM - A progress note in R77's clinical record documented that the resident was not given their ordered clonazepam because pharmacy was awaiting signature. 4/5/26 10:48 PM - A progress note in R77's clinical record documented Medication not available. Called pharmacy, prescription on file not valid. Called team health, spoke with NP and requested script to be sent to pharmacy. NP herself was unable to send prescription but will attempt to get peer to send script to pharmacy. Provided with pharmacy phone and fax numbers. April 2026 - Review of R77's MAR revealed missed doses of the resident's anxiety medication on the following dates/times:4/4 - 10:00 PM4/5 - 8:00 AM4/5 - 10:00 PM. 4/6/26 - A pharmacy invoice of delivered medications documented arrival of R77's clonazepam. 5/18/26 9:45 AM - During an interview R77 stated, They stopped my medication I have severe anxiety. They stopped my Klonopin/clonazepam for no reason when I came. 2. Review of the Medex Drug information website revealed, Missing doses of quetiapine significantly increases the risk of relapse for conditions like schizophrenia and bipolar disorder. Understanding what happens if you miss doses of quetiapine is crucial for managing your mental health effectively and preventing complications. What Happens if you Miss Doses of Quetiapine? medexdrg.com. Review of R2's clinical record revealed; 4/8/26 3:24 PM - R2 was admitted to the facility with multiple diagnoses including Major Depressive and Mood disorder. 4/8/26 - A physician's order was written for R2 to receive quetiapine an antipsychotic medication daily at 9:00 PM for mood disorder. 4/9/26 3:22 AM - A progress note in R2's clinical record documented that R2 did not receive the quetiapine because it was not yet delivered from the pharmacy. 4/9/26 3:33 PM - A pharmacy invoice of delivered medications documented that R2's quetiapine was delivered. 4/9/26 - 11:49 PM - A progress note in R2's clinical record documented that R2 did not receive the quetiapine because it was not yet delivered from the pharmacy. 4/14/26 - An admission MDS assessment documented that R2 received antipsychotic medications. 4/14/26 - A care plan was created for R2's use of antipsychotic medications. April 2026 - Review of R2's MAR lacked evidence that R2 received the ordered quetiapine on 4/8 and 4/9. 5/20/26 10:51 AM - During an interview E15 (RNUM) confirmed that R2's medications were not administered for two doses. E15 stated if we call the pharmacy before 6:00 PM then they will deliver by the next day. During the same interview E15 (RN) and staff developer reported, if it is a STAT medication than we can usually get it right away but most medications come the following morning. 5/20/26 10:56 AM - During an interview E8 (LPN) confirmed that at times newly admitted residents do not have all their medications. E8 stated, We then go to back up and tell the supervisor. 5/20/26 10:59 AM - During an interview E14 (LPN) confirmed that sometimes newly admitted residents do not have all their medications. E14 stated, When they don't we check the emergency box to see if any of the medication is there. We call the doctor to see if we can get a hold. Review of the facilities emergency medication inventory list revealed that quetiapine is not a medication stored int he emergency box. 5/21/26 11:52 AM - During an interview E2 (DON) confirmed that pharmacy delivery for new residents can be 24 to 48 hours resulting in missed dosages of medication for R2 and R77. E2 stated, The delivery run is 11:00 AM and 3:00 AM and something in the afternoon. Our pharmacy is in Baltimore so it takes time. 5/22/25 3:40 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2 (DON).

Based on observation and interview, it was determined that for three (R16, R38, and R234) out of twenty-four (24) residents in the investigative sample, the facility failed to ensure residents were treated with respect and dignity. Findings include: 1. Review of R16's clinical record revealed: 4/24/25 - R16 was admitted to the facility. 5/12/25 10:42 AM - During an observation, E14 (PTA) knocked on R16's room door and entered the room without waiting for R16's response/permission to enter the room. 5/12/25 10:43 AM - During an interview, E14 (PTA) confirmed that the expectation is to knock and wait for a response to enter a resident's room. E14 confirmed that she did not wait for a response before entering R16's room. 5/12/25 11:00 AM - During an observation, E15 (RN) knocked on R16's room door and entered the room without waiting for R16's response/permission to enter the room. 5/12/25 11:25 AM - During an interview, E15 (RN) confirmed that the expectation is to knock and wait for a response to enter a resident's room. E15 confirmed that she did not wait for a response before entering R16's room. 2. Review of R38's clinical record revealed: 4/30/25 - R38 was admitted to the facility. 5/12/25 10:36 AM - During an observation, E14 (PTA) knocked on R38's room door and entered the room without waiting for R38's response/permission to enter the room. 5/12/25 10:43 AM - During an interview, E14 (PTA) confirmed that the expectation is to knock and wait for a response to enter a resident's room. E14 confirmed that she did not wait for a response before entering R38's room. 3. Review of R234's clinical record revealed: 5/13/25 9:57 AM - During an observation, E16 (Dietary) knocked on R234's room door and entered the room without waiting for R234's response/permission to enter the room. 5/13/25 9:58 AM - During an interview E16 (Dietary) confirmed that the expectation is to knock and wait for a response to enter a resident's room. E16 confirmed that she did not wait for a response before entering R234's room. 5/13/25 10:19 AM - During an observation, E17 (Housekeeping) knocked on R234's room door and entered the room without waiting for R234's response/permission to enter the room. 5/13/25 10:25 AM - During an interview, E17 (Housekeeping) confirmed that the expectation is to knock and wait for a response to enter a resident's room. E17 confirmed that she did not wait for a response before entering R234's room. 5/20/25 2:15 PM - Findings were reviewed with E1 (ED) and E2 (DON).

Based on observation and interview, it was determined that for one (R336) out of five residents observed during medication administration the facility failed to use enhanced based precautions for a resident with a central line. Findings include: A facility policy issued 3/27/24, to be implemented by 4/5/24 titled Enhanced Barrier Precautions .designed to reduce transmission of multidrug -resistant organisms that employs targeted gown and glove use during high contact resident care activities .device care or use: central line, urinary catheter, feeding tube. Review of R336's clinical record revealed: 5/8/25 - R336 was admitted to the facility with a diagnosis of a stroke. 5/12/25 - A care plan for R336 revealed enhanced barrier precautions related to the presence of a central line for the administration of an antibiotic. 5/15/25 1:54 PM - During medication administration, E13 was observed entering R336's room and administered IV Merrem through a central line. E13 completed hand hygiene and applied gloves, but did not put on the required personal protective equipment which includes a gown in addition to the gloves. 5/15/25 2:05 PM - During an interview, E13 confirmed that he did not wear a gown and that a gown and gloves should be worn due to R36 being on enhanced barrier precautions. 5/20/25 2:15 PM - Findings were reviewed with E1 (ED) and E2 (DON).

Based on record review and interview, it was determined, for one (R78) out of one resident reviewed for laboratory services, the facility failed to promptly notify the ordering medical practitioner of laboratory results that fell outside of clinical reference ranges. Findings include: Cross refer F690. Review of R336's clinical record revealed: 5/10/25 8:13 PM - A nursing note written by E3 (RN) documented . Call placed to Team Health on call and spoke with E4 (on call provider) who gave order for Urinalysis (UA), Culture and Sensitivity (C&S). Order noted . 5/11/25 6:04 AM - Administration history notes documented R78's urine sample was collected. 5/12/25 5:00 AM - A lab report in the electronic medical record (EMR) revealed the lab collected the urine sample from the facility. 5/12/25 10:38 AM - A lab report in the EMR revealed the urine sample was received from the facility. 5/12/25 6:41 PM - A lab report in the EMR revealed abnormal UA results with moderate blood, positive nitrates, and 10-20 white blood cells was reported to facility with C&S pending. 5/13/25 9:28 AM - A lab report in the EMR revealed the UA results were acknowledged and signed off by E5 (NP). 5/16/25 10:10 AM - During an interview, E9 stated when laboratory results are received, they are uploaded into Point Click Care (facility's charting system) and faxed to the nursing unit. The nurse is responsible for reviewing the results and notifying the provider. If results return during the day shift (before 7:00 PM), the nurse typically provides verbal notification with a copy of the results to the provider while they are rounding on the unit. If results return after 7:00 PM, Monday through Thursday, and 7:00 PM Friday through 7:00 AM Monday, the nurse contacts the Team Health on call service to report the findings and obtain any necessary orders. Following provider notification, the nurse is expected to document the interaction in a progress note, including who was notified, the lab results communicated, and any orders received. 5/16/25 3:14 PM - During an interview, E12 (MD) stated that it is standard practice for the dayshift charge nurse to monitor for any pending lab results and provide the provider with a printed copy of any abnormal findings that require follow-up. If providers have already left for the day, it is expected that the nurse will notify the Team Health on call provider of any abnormal lab results that return after 7:00 PM, Monday through Thursday, and 7:00 PM Friday through 7:00 AM Monday. E12 (MD) confirmed that the facility lacked documentation indicating that a provider was notified when the abnormal UA lab result was received. 5/20/25 2:15 PM - Findings were reviewed with E1 (ED) and E2 (DON).

Based on interview and record review, it was determined that for one (R76) out of five residents sampled for medication review, the facility failed to limit a PRN psychotropic medication to 14 days. Findings include: Review of R76's clinical record revealed: 4/23/25 - R76 was admitted to the facility. 4/23/25 - A physician's order was written for lorazepam (anti-anxiety) 2 mg: give one tablet by mouth every twelve hours as needed for anxiety with an indefinite end date. 4/25/25 - A pharmacy communication documented that R76 was receiving a PRN psychotropic medication and did not have an indicated stop date. 4/25/25 - A physician's order was written for lorazepam 2 mg: give one tablet by mouth every 12 as needed for anxiety for 14 days. 5/9/25 - A physician's order was written for lorazepam 1mg: give one tablet by mouth every 12 hours as needed for anxiety with an indefinite stop date. 5/20/25 9:32 AM - During an interview, E5 (NP) confirmed the expectation for PRN psychotropic medication should have a 14 day stop date. E5 confirmed the aforementioned orders were written with an indefinite stop date. 5/20/25 2:15 PM - Findings were reviewed with E1 (ED) and E2 (DON).

Based on interview and record review it was determined that for two (R15 and R78) out of four residents reviewed for bowel and bladder, the facility failed to provide services to maintain or restore bowel and bladder continence for R15. For (R78), the facility failed to initiate antibiotic therapy for a resident without a urinary catheter who met criteria. Findings include: 1. Review of R15's clinical record revealed: 3/28/25 - R15 was admitted to the facility. 3/28/25 3:54 PM - A Nursing Comprehensive admission Data Collection Assessment documented that R15 was incontinent of bladder for less than a week and was occurring one to two times a day. Additionally the assessment documented R15 was wet during the day and night time and amount of urine was a large amount resulting in puddles, clothes, bed, or floor. 4/1/25 - A base line care plan was initiated for R15 documenting that R15 had bowel or bladder incontinence with interventions as follows: check frequently and assist with toileting as needed, keep call light within reach, provide loose fitting and easily removable clothing, and provide pericare after each incontinent episode and apply barrier cream as needed. 4/2/25 - An admission MDS documented that R15 required an assist of one person for toileting transfer, toileting hygiene, and lower body dressing. Additionally, the MDS documented that R15 was frequently incontinent of urine and no toileting program in place to manage urinary incontinence. A BIMS score of 6 was noted on admission MDS indicating moderate cognitive decline. 4/2025 - The April CNA documentation record revealed that R15 was continent of urine 10 out of 90 opportunities. 5/2025 - The May CNA documentation record revealed that R15 was continent of urine 3 out of 54 opportunities. 5/12/25 - During an interview, R15 stated he was continent of urine when staff assists him to the toilet. 5/19/25 2:22 PM - During an interview, E21 (CNA) stated that R15 requires an assist of one and uses the toilet with staff assistance. E21 stated the standard is toileting every two hours and confirmed that R15 was not on a toileting program or voiding diary. 5/20/25 10:57 AM - During an interview, E15 (RN) stated that a toileting program is a standard every two hours and as needed for all residents. E15 stated that toileting programs and voiding diaries are not personalized and occur every two hours. E15 confirmed that R15 was not on an individualized toileting program to address his incontinence needs. 2. Review of R78's clinical record revealed: An undated protocol titled Urine dip protocol was provided by E9 and documented . 1. Only order a urine dip if a resident is symptomatic: fever, new onset dysuria (burning or pain with urination), or changes in urinary frequency or urgency . 2. If positive, notify MD (physician), document [results] in a progress note, order urine culture to be sent out, and enter an order in PointClickCare (the facility's charting system) to result to MD once completed. 4/27/25 - R78 admitted to facility for rehab with diagnoses including but not limited to right and left broken arm. 5/10/25 7:45 PM - The facility Urine Dip Protocol revealed positive nitrates (presence of bacteria) and small leukocytes (white blood cells). 5/10/25 8:13 PM - A nursing note written by E3 (RN) documented .Informed by day shift nurse pt [patient] c/o [complained of] burning [dysuria] on urination. Urine collected and dipstick completed. + [positive] for nitrates and small amount of leukocytes. Call placed to Team Health on call and spoke with E4 (on call provider) who gave order for Urinalysis (UA), Culture and Sensitivity (C&S). Order noted . 5/11/25 6:04 AM - A lab report in the electronic medical record (EMR) revealed the urine sample for UA and C&S was obtained. 5/12/25 5:00 AM - A lab report in the EMR revealed the lab received the urine sample for UA and C&S from the facility. 5/12/25 6:41 PM - A lab report in the EMR revealed abnormal UA results with moderate blood, positive nitrates, and 10-20 white blood cells was reported to facility with C&S pending. 5/13/25 9:28 AM - A lab report in the EMR revealed UA results were acknowledged and signed off by E5 (NP). An order placed by E5 included: Macrobid (antibiotic) Oral Capsule 100 MG. Give 1 capsule by mouth two times a day for UTI for 7 Days to start 5/13/25 at 9AM. 5/14/25 6:02 PM - A lab report in the EMR revealed an E. Coli colony count >100,000 cfu/ml indicating a positive C&S. 5/14/25 10:06 PM - A nursing note written by E7 (RN) documented . Urine C&S result received. TeamHealth on call Physician paged. Waiting for call back . 5/14/25 11:36 PM - A nursing note written by E7 (RN) documented .E6 (NP) returned call and was made aware of Urine C&S result. New order received to D/C Macrobid and start Cipro 500mg BID X 5 days . 5/16/25 11:37 AM - During an interview, R78 confirmed that she informed staff on 5/10/25 that she was experiencing burning with urination. R78 stated that a urine sample was collected, tested at the facility using a dipstick, and then sent to an outside laboratory for further analysis and culture. R78 reported that she continued to experience and report burning with urination following the initial complaint but was not started on any treatment at that time. R78 experienced dysuria and had a pending urine culture, meeting the minimum criteria for initiating antibiotic therapy in a resident without a urinary catheter. However, the facility failed to initiate antibiotics despite the resident meeting these criteria. 5/20/25 2:15 PM - Findings were reviewed with E1 (ED) and E2 (DON).

Based on interview and record review it was determined that for one (R38) out of twenty-four residents reviewed in the investigative sample, the facility failed to follow a physician's order. Findings include: 1. Review of R38's clinical record revealed: 4/30/25 - R38 was admitted to the facility. 4/30/25 - A physician's order was written for metoprolol tartrate 25 mg give one tablet by mouth two times a day for hypertension and hold for SBP (systolic blood pressure) less than 110 and heart rate less than 60. 5/2025 - The May MAR documented metorprolol tartrate 25 mg given on the following dates when the systolic blood pressure or heart fell outside of the parameters: -5/11/25 BP 124/59 HR 55. -5/13/25 BP 128/62 HR 58. -5/14/25 BP 145/60 HR 55. -5/15/25 BP 143/62 HR 55. 5/20/25 9:41 AM - During an interview, E5 (NP) stated the expectation with medications not meeting parameters to administer should be reported to the medical provider and the expectation was for the medication to be held. E5 confirmed that she was not aware of R38's medication being held for parameters and confirmed that medication was administered with no adverse effects noted. 5/20/25 10:40 AM - During an interview, E15 (RN) stated the expectation with medications not meeting parameters would be to hold the medication and explain to the resident why it is being held. E15 also stated that the medication being held should be reported to the provider. E15 confirmed that R38's medication was administered from the aforementioned dates. 5/20/25 2:15 PM - Findings were reviewed with E1 (ED) and E2 (DON).

Based on record review and interview, it was determined that for two (R15 and R76) out of twenty-four residents in the investigative sample, the facility failed to provide services that meet professional standards of quality by having Licensed Practical Nurses (LPN) complete admission assessments. Findings include: Delaware State Board of Nursing - RN, LPN and NA/UAP Duties 2024 . admission Assessments * - RN .* = Once a care plan is established, the LPN may do assessments . 1. Review of R15's clinical record revealed: 3/28/25 - R15 was admitted to the facility. 3/28/25 3:54 PM - A Nursing Comprehensive admission Data Collection assessment was completed by E23 (LPN). The nursing Comprehensive admission Assessment reviewed R15's demographics, drug regimen review, self care and mobility activities, skin, sensory perception, oral/nutritional, neurological, respiratory, cardiovascular, gastrointestinal, dehydration risk screener, bladder/bowel, sleep, pain, and fall risk. 3/29/25 3:14 PM - A Functional Abilities and Goals Admission assessment was completed by E8 (RN). The Functional Assessment reviewed R15's prior functioning, prior device use, self care, and mobility. 5/20/25 10:57 AM - During an interview, E15 (RN) stated the expectation was if the LPN was assigned to the pending admission then the LPN would complete the Nursing Comprehensive admission Data Collection and the RN would complete the Functional Assessment and any other Assessments. E15 confirmed that the comprehensive admission data collection was completed by E23 (LPN). 2. Review of R76's clinical record revealed: 4/23/25 - R76 was admitted to the facility. 4/23/25 10:35 PM - A Functional Abilities and Goals Admission assessment was completed by E24 (RN). The Functional Assessment reviewed R76's prior functioning, prior device use, self care, and mobility. 4/24/25 2:35 AM - A Nursing Comprehensive admission Data Collection assessment was completed by E23 (LPN). The Nursing Comprehensive admission Assessment reviewed R76's demographics, drug regimen review, self care and mobility activities, skin, sensory perception, oral/nutritional, neurological, respiratory, cardiovascular, gastrointestinal, dehydration risk screener, bladder/bowel, sleep, pain, and fall risk. 5/20/25 10:57 AM - During an interview, E15 (RN) stated the expectation was if the LPN was assigned to the pending admission then the LPN and the Nursing Comprehensive admission Data Collection and the RN would complete the Functional Assessment and any other assessments. E15 confirmed that the Comprehensive admission Data Collection was completed by E23 (LPN). 5/20/25 2:15 PM - Findings were reviewed with E1 (ED) and E2 (DON).

Based on record review and interview it was determined that for one residents (R68) out of twenty-four residents reviewed the facility failed to have input from all required interdisciplinary team (IDT) members at the residents' care plan meetings. Findings include: Review of R68's clinical record revealed: 4/8/25 - R68 admitted to facility. 4/14/25 - An admission MDS was completed for R68. 5/12/25 - Review of R68's clinical record lacked evidence that a care plan meeting occurred with the case manager and R68. 5/12/25 2:05 PM - During an interview, R68 stated that each week the facility's case manager meets with her and her husband to discuss the care she is receiving and the plans for discharge, which are reviewed during the facility's weekly Interdisciplinary Team (IDT) meetings. R68 explained that she is not present during the IDT meetings, but the case manager provides a summary of the discussions held by the staff present regarding her care. 5/16/25 9:38 AM - During an interview, E1 (ED) stated that Interdisciplinary Team (IDT) meetings occur weekly and include all staff members. Additionally, the Case Manager/Social Worker (SW) meets with the resident and the resident's representative on a biweekly basis. These biweekly meetings are considered the formal care plan meetings. 5/19/25 10:51 AM - During an interview, E2 (DON) confirmed that the IDT meeting notes do not reflect that all the members are present or input is provided. 5/20/25 2:15 PM - Findings were reviewed with E1 (ED) and E2 (DON).

Based on interview and record review, it was determined that for one (R76) out of twenty-four residents in the investigative sample, the facility failed to develop a comprehensive resident centered care plan for an identified care area. Findings include: Review of R76's clinical record revealed: 4/23/25 - R76 was admitted to the facility. 4/23/25 - A physician's order was written for enoxaparin sodium (anti-coagulant) inject 40 mg subcutaneously one time a day for DVT (deep vein thrombosis) prophylaxis. Additionally, a physician's order was written to monitor side effects of anticoagulant medication for signs and symptoms of bleeding and report any complications to the physician. 4/24/25 - A care plan was initiated for R76 and lacked evidence of a care plan related to anti-coagulant use. 5/16/25 1:24 PM - During an interview, E19 (MDS Coordinator) stated the process was the admission nurse will initiate the baseline care plan and after the MDS was completed the MDS coordinator will add any additional care plans identified during completion of the MDS. E19 confirmed that a care plan for anticoagulant use was not initiated for R76. 5/20/25 2:15 PM - Findings were reviewed with E1 (ED) and E2 (DON).

Based on record review and interview, it was determined that for one (R24) out of two residents reviewed for abuse, the facility failed to report the allegations of abuse to the State Agency within two hours. Findings include: A facility policy titled, Abuse and Neglect Prohibition last revised October 12, 2022, documented: 1. State Reporting Obligations: The facility will report all allegations and substantiated occurrences of abuse, neglect . to the administrator, State Survey Agency . in accordance with Federal and State law through established procedures. a. If the events that caused the allegation involve abuse .a report is made not later than 2 hours after the management staff becomes aware of the allegation 1. Review of R24's clinical record revealed: 4/15/25 - R24 was admitted to the facility. 4/16/25 - A BIMS assessment documented that R24 was cognitively intact with a score of 15. 5/10/25 - R24 stated that nursing staff touched her inappropriately while taking vital signs. 5/12/25 3:01 PM - E1 (ED) reported the allegation of abuse incident to the State Agency. 5/19/25 9:22 AM - During an interview, E10 (RN) stated that on 5/10/25, E11 (LPN) notified her about an allegation of abuse from R24. E10 stated that she went to interview R24, and R24 stated that a nurse on the overnight shift had touched the side of her breast while taking her vital signs. E10 then stated she let E2 (DON) know that same day. E10 then continued to do interviews for the investigation. 5/19/25 1:35 PM - During an interview, E2 stated that E10 did tell her about the incident from R24 on 5/10/24 and asked E10 to do the investigation. E2 further confirmed this was an allegation of abuse and explained that was why the investigation was started that day. The report of the alleged abuse was submitted two days after the alleged incident occurred. 5/20/25 2:15 PM - Findings were reviewed with E1 and E2.

Based on interview and record review, it was determined that for three (R38, R76, and R234) out of four residents reviewed for Advance Directives, the facility failed to offer an opportunity to formulate an advance directive. Findings include: 1. Review of R38's clinical record revealed: 4/30/25 - R38 was admitted to the facility. 5/1/25 - A BIM's assessment was completed for R38 with a score of 15 indicating R38 was cognitively intact. 5/1/25 11:05 AM - A social history assessment was completed for R38 and documented that R38 was a full code and had a general POA. The assessment did not determine if R38 had an advanced directive or wanted to formulate one. 5/14/25 10:38 AM - During an interview, E18 (Clinical Liaison) confirmed that the admitting nurse is responsible to review admission documents with the residents upon admission. 5/14/25 10:42 AM - During an interview, E13 (LPN) confirmed that the admitting nurse is responsible to complete the resident assessments. 5/14/25 12:17 PM - During an interview, E1 (NHA) and E2 (DON) stated that the physician will discuss advanced care options with the residents during an exam. 2. Review of R76's clinical record revealed: 4/23/25 - R76 was admitted to the facility. 4/24/25 - A BIM's assessment was completed for R76 with a score of 15 indicating R76 was cognitively intact. 4/24/25 4:02 PM - A social history assessment was completed for R76 and documented that R76 was a full code. The assessment did not determine if R76 had an advanced directive or wanted to formulate one. 5/14/25 10:38 AM - During an interview, E18 (Clinical Liaison) confirmed that the admitting nurse is responsible to review admission documents with the residents upon admission. 5/14/25 10:42 AM - During an interview, E13 (LPN) confirmed that the admitting nurse is responsible to complete the resident assessments. 5/14/25 12:17 PM - During an interview, E1 (NHA) and E2 (DON) stated that the physician will discuss advanced care options with the residents during an exam. 3. Review of R234's clinical record revealed: 5/9/25 - R234 was admitted to the facility. 5/10/25 12:02 PM - A BIM's assessment was completed for R234 with a score of 15 indicating R234 was cognitively intact. 5/11/25 6:30 AM - A social history assessment was completed for R234 and documented that R234 was a full code. The assessment did not determine if R234 had an advanced directive or wanted to formulate one. 5/14/25 10:38 AM - During an interview, E18 (Clinical Liaison) confirmed that the admitting nurse is responsible to review admission documents with the residents upon admission. 5/14/25 10:42 AM - During an interview, E13 (LPN) confirmed that the admitting nurse is responsible to complete the resident assessments. 5/14/25 12:17 PM - During an interview, E1 (NHA) and E2 (DON) stated that the physician will discuss advanced care options with the residents during an exam. The facility lacked evidence of offering an opportunity to formulate an advance directive for R38, R76 and R234. 5/20/25 2:15 PM - Findings were reviewed with E1 (ED) and E2 (DON).

Based on interview and record review it was determined that one (R336) out of four residents reviewed for Advanced Directives, the facility failed to ensure that a responsible party of a cognitively impaired resident was involved in code status decisions. Findings include: Review of R336's clinical record revealed: 3/1/25 - R336 was admitted to the facility with diagnoses including but not limited to prostate cancer with secondary bone cancer and unsteady gait. 3/3/25 6:20 PM - FM1 signed the Delaware Medical Orders for Scope of Treatment (DMOST) form indicating FM1 as R336's responsible party (RP). 3/5/25 - E12 (MD) signed DMOST form. 5/8/25 - R336 was re-admitted to facility with diagnoses including but not limited to, cerebral infarction (stroke). 5/8/25 - R336 signed DMOST form. 5/9/25 - E5 (NP) signed DMOST form. 5/9/25 - A Brief Interview for Mental Status (BIMS) assessment documented R336's BIMS score as 5, indicating severe cognitive impairment. 5/20/25 9:55 AM - During an interview, E5 (NP) stated that the facility utilizes the BIMS score when assessing a resident's cognitive capacity. E5 (NP) further explained that she would expect a resident to have a BIMS score between 14 and 15 to be considered cognitively intact and capable of signing medical documents independently and for residents with lower BIMS scores indicating severe cognitive impairment, the provider is expected to obtain input from the resident's responsible party (RP) with another staff member present as a witness, in conjunction with the provider. E5 (NP) confirmed R336 documented BIMS score was 5 and R336's RP was not contacted for their input at the time R336 signed the DMOST form. The facility failed to involve R336's RP in the decision-making process and ensure another staff member was present to witness the discussion and signing. 5/20/25 2:15 PM - Findings were reviewed with E1 (ED) and E2 (DON).

Based on observation, interview, and record review it was determined that for one (R3) out of three residents reviewed for ADL (Activities of Daily Living) the facility failed to provide nail care. Findings include: A facility policy and procedure titled, Dignity updated, 3/14/24 documented: Patients shall receive assistance with activities of daily living (ADLs) every shift, as appropriate. ADLs include bathing, grooming, dressing, eating, oral hygiene, ambulation, toilet activities and trimming of toenails. Review of R3's clinical record revealed: 5/15/24 - R3 was admitted to the facility. 5/15/24 - Review of R3's care plan for ADL's revised 5/26/24 documented interventions included provide assistance as needed with grooming, bathing, and personal hygiene and per patient's preferences and R3 required an assist of one for grooming and personal hygiene. Further review of R3's care plan lacked evidence that R3 had refused nail care. 5/17/24 - Review of R3's care plan for confusion/forgetfulness revised 5/26/24 documented interventions included assist as needed. 5/20/24 - An admission MDS assessment revealed R3 was moderately cognitively impaired. R3 required substantial maximum assist of one for showers and bathing and partial moderate assist of one for toileting. 6/6/24 10:30 AM - A random observation of R3's hands revealed dark encrusted debris underneath each fingernail on the right and left hand. Additionally, R3's fingernails were long and needed to be trimmed on both hands. 6/7/24 9:36 AM - During a telephone interview R3's FM1 stated, I have asked them a couple of times to cut them, but the staff just take their time doing things. 6/10/24 9:40 AM - A second observation revealed R3's fingernails on the right and left hand had not been cut and R3 continued to have dark encrusted debris underneath his fingernails. 6/10/24 10:52 AM - During an observation E20 (CNA) entered R3's room. E20 asked [R3], are you ready to get washed up. [R3] said, yes. E20 then left R3's room. 6/10/24 10:55 AM - E20 was observed entering R3's room to provide care. 6/10/24 11:09 AM - During an interview E20 stated, Usually I do nail care if I see that a resident's fingernails are physically dirty, and they need to be cut or if they ask me to while I am doing care, then I would do nail care. 6/10/24 2:10 PM - R3's fingernails remained long on both hands with dark encrusted debris underneath his fingernails on both hands. 6/11/24 8:30 AM - R3's fingernails had not been cut and continued to have dark encrusted debris underneath his fingernails on both hands. 6/11/24 8:33 AM - During an interview and observation E19 (RN, UM) stated, Usually they do an assessment of the nails to see if they need to be cut or when the resident gets their shower. E20 confirmed R3's fingernails were dirty and needed to be cut. E20 updated the staff and requested that R3 be provided nail care. The facility failed to provide appropriate support and assistance for R3's personal hygiene and grooming when the facility failed to cut and trim R3's fingernails in accordance with R3's documented plan of care. Findings were reviewed during the exit conference on 6/13/24 at 2:30 PM with E1 (NHA) and E2 (DON) and representatives from the Ombudsman.

Based on interview and record review, it has been determined that for one (R46) out of forty five residents reviewed for care plans, the facility failed to develop a care plan to address wax build up in the ears. Findings include: 5/18/24 - R46 was admitted to the facility. 5/31/24 11:00 AM - A physician's order written for R46 documented, Debrox Otic (relating to the ear) Solution 6.5% (Carbamide Peroxide) Otic instill five drop (sic) in both ears two times a day for earwax for five days flush with warm water on the fifth day. 6/7/24 10:53 AM - A physician's order written for R46 documented, Debrox Otic (relating to the ear) Solution 6.5% (Carbamide Peroxide) Otic instill five drop (sic) in both ears two times a day for earwax for five days flush with warm water on the fifth day. 6/13/24 10:30 AM - Further review of R46's clinical record lacked evidence that a person centered care plan had been created to address the wax build up in R46's ear. 6/13/24 10:45 AM - During an interview E19 (RN, UM) confirmed that a care plan had not been created for wax build up in R46's ear. Findings were reviewed during the exit conference on 6/13/24 at 2:30 PM with E1 (NHA) and E2 (DON) and representatives with the Ombudsman office.