Every finding on record at Delaware Court Health Care Center

Based on medical record review and staff interview, the facility failed to ensure fall interventions were in place as ordered. This affected one Resident (#39) out of four Residents (#6, #39, #51, and #58) reviewed for fall incidents and accident prevention. The facility census was 59.Findings Include:Review of the medical record for Resident #39 revealed the resident was admitted to the facility on [DATE]. Diagnoses included late onset Alzheimer's disease, dementia in other diseases, and anxiety disorder amongst other diagnoses. Further review of Resident #39's medical record revealed a Brief Interview for Mental Status (BIMS) score could not be evaluated as the resident was rarely or never understood as of the Minimum Data Set (MDS) 3.0 assessment completed on 04/03/26, though the resident was noted to have severe cognitive impairment.Review of the physician orders revealed Resident #39 had an order for an alarm to be placed in the resident's chair and bed every shift for safety, with a start date of 02/24/26 and an end date of 05/18/26. Additional review of the physician orders revealed continued alarm orders after 05/18/26, including an order for a pressure alarm to be used while in bed along with checking to ensure the correct functioning and placement (start date 05/18/26), and a tab alarm used while up in chair/wheelchair, checking function and placement each shift (start date 05/18/26). Review of the progress notes in Resident #39's medical record revealed a nurse's note, dated 05/16/26 at the time 9:34 PM documented Certified Nursing Assistants (CNAs) came to notify the nurse/author of the note that Resident #39 had fallen from their wheelchair while in the hallway on the evening of 05/16/26 around 8:15 P.M. Further review of this progress note revealed Resident #39 was found lying on their left side on the floor, with bleeding above their left eye and at their left hand. Additional review of this progress note revealed staff were instructed not to move the resident, neurological checks were initiated, an Emergency Medical Services (EMS) squad was promptly called to send the resident to the hospital for further assessment and treatment, and the EMS squad arrived 8:22 P.M. on 05/16/26.Further review of progress notes contained in Resident #39's medical record revealed another nurse's note, dated 05/16/26 at the time 11:49 PM revealed Resident #39 returned to the facility from the hospital at 10:49 P.M. on 05/16/26. Review of this progress note revealed that while at the hospital, computed tomography (CT) scans of the cervical spine (spine area near the neck) and the head or brain, both without contrast were completed for Resident #39 with no reported findings on discharge paperwork or from the EMS squad upon the resident's return to the facility. Further review of this progress note revealed Resident #39 returned to the facility with steri-strips (adhesive strips used to hold skin together for healing in cases where sutures/stitches are often not needed) applied at their left forehead and left hand. The resident was noted to have been diagnosed with skin tears at both the left forehead and left wrist while at the hospital after their fall on the evening of 05/16/26.Review of an additional nurse's note found in Resident #39's medical record, dated 05/16/26 at the time 11:50 PM revealed fall intervention education to staff was completed to ensure Resident #39's bed/chair alarm was in place and powered on when assisting the resident to bed and assisting the resident into their wheelchair, because the chair alarm was not found in the resident's wheelchair at the time they fell, although there were active orders for it at the time of the fall. Further review of this progress note revealed when the resident fell out of their chair, it was noted that she did not have chair alarm in her w/c.Interview on 06/04/26 at 4:42 P.M., with Registered Nurse (RN) #93 revealed they were working during the shift when Resident #39 fell on [DATE] and verified no chair alarm was found in Resident #39's wheelchair at the time the resident was found on the floor and noted to have fallen out of their wheelchair around 8:15 P.M. on that evening. Further interview with RN #93 at this time revealed they believed the wheelchair alarm would likely not have stopped Resident #39 from trying to get out of their wheelchair on their own, though had the alarm been placed as it should have been, perhaps the sound of the alarm would have notified staff who may have been able to prevent the fall.Interview on 06/04/26 at 6:00 P.M., with the Interim Director of Nursing (DON) verified their knowledge of the events that occurred in relation to Resident #39's fall on 05/16/26 was consistent with the documentation available in the medical record, and that a soft file of an investigation had been completed for the fall. Further interview with the DON at this time revealed a care conference was held with the Interdisciplinary Team (IDT) and Resident #39's family shortly after the resident returned to the facility from the hospital to review fall interventions in place for Resident #39 and discuss options to prevent future falls.This deficiency represents non-compliance investigated under Complaint Number 3013574.

Based on observation, staff interviews, and policy review the facility failed to ensure food was stored in a safe and sanitary manner, failed to ensure proper hand hygiene was completed when making puree food, taking food temperatures and during tray line service and failed to ensure the kitchen maintained proper sanitation. This affected all Residents except Resident #2 who did not eat food from the kitchen. Facility census was 59. Findings include1. Observation on 09/30/25 from 08:10 A.M. to 8:25 A.M. revealed a bowl of cookies in envelopes with no date on the bowl or on the individual envelopes. A tray of cookies sitting on the prep table on a cookie sheet that was not covered. Three pre made sandwiches wrapped in foil were left in the fridge and were undated and unlabeled. A large metal bowl with fajita mix was covered with plastic wrap and was not dated. A bag of vanilla wafers was open to air and not sealed. 14 chocolate magic cups were thawed and the container/package stated to keep frozen. Six cups of yogurt were found to be undated. A red bowl was found in the fridge with an unknown substance in it was undated and an open bottle of water was found to be undated. Two cups of pre-poured orange juice, two cups of pre-poured milk and one cup of pre-poured apple juice were also left undated. Interview on 09/30/25 at 8:25 A.M. with Kitchen Manager #141 confirmed food storage findings and revealed items should be covered, labeled and dated. Review of the facility policy titled Dry Storage Areas dated 2023, revealed dry storage areas shall be maintained to keep food safe and free of infestation or contamination. Review of the facility policy titled Food Storage dated 2023, revealed storage areas shall be maintained to keep food safe and free of cross contamination or contamination. All stock shall be rotated using first in and first out method. Food should be dated as it was placed on the shelf. Plastic containers with tight fitting covers or sealed plastic bags must be used for storing opened packages and all containers must have legible and accurate labels and dates. 2. Observation and interview on 09/30/25 at 11:57 A.M. with Dietary staff #144 revealed he was making puree salmon patties. During the blending process Dietary staff #144 blended three salmon patties and broth in the roboku mixer. Dietary staff reached his gloved hand into the mixer and scraped the sides. Then with the same gloved hand, grabbed a jar of broth to add in more liquid and continued to use his same gloved hand to scrape the sides of the blender. He reported staff had been instructed to use their hand to scrape the inside of the blender and were told they were not allowed to use kitchen utensils such as a spatula. The Dietary staff member did not preform any hand hygiene between each time of reaching in the blender and scraping the sides and grabbing other kitchen items (broth) and pressing buttons on the roboku blender. Observation and interview on 09/30/25 at 12:25 P.M. with Dietary staff #183 confirmed he took food temperatures and stuck his fingers in the food (baked beans) then used his fingers to wipe the thermometer then used a sanitizer wipe and without preforming hand hygiene/switching gloves, he placed the thermometer in the salmon patties and repeated the process before placing the thermometer in the potatoes. Dietary staff #183 confirmed he used his gloves to wipe the thermometer which soiled his gloves that were also not changed, then he stuck his fingers in the food items. Observation and interview on 09/30/25 at 12:40 P.M. with Kitchen Manager #141 revealed Dietary staff #144 pulled a roll from the bag and cut in half with a knife then with the same gloves grabbed food on the tray line (salmon patty) with his hands. The Kitchen Manager confirmed staff should have changed gloves and instructed him to change his gloves anytime he touches food. Review of the facility policy titled Hand Washing undated, revealed hands and exposed portions of arms shall be washed in accordance with established standards of practice to prevent cross contamination. Employees shall change gloves as necessary and wash hands after handling soiled equipment and utensils, between handling soiled and clean dishes, and when changing tasks. Review of the facility policy titled Disposable Gloves undated, revealed gloves shall be worn to prevent cross contamination. They shall be worn when handling food to avoid contact with bare hands and shall be used for one task and then discarded when damaged or soiled. Handwashing should occur prior to putting on gloves and when gloves were changed. 3. Observations on 09/30/25 from 11:57 A.M. to 3:47 P.M. revealed the overhead vents in the kitchen over the food preparation and food service area were dirty and had a thick layer of dust on them. Interview on 09/30/25 at 3:48 P.M. with Kitchen Manager #141 confirmed the confirmed the area was dirty and dust was blowing above food preparation areas. This deficiency represents non-compliance investigated under Complaint Number 2661246.

Based on observation, record review and staff interview, the facility failed to ensure puree food was made to the correct consistency. This affected six residents (#7, #21, #25, #28, #42, and #52) who had orders for puree food. Facility census was 59. Findings include:1. Review of the medical record for Resident #7 revealed an admission date of 10/29/21. Diagnoses included cerebral infarction, respiratory failure, protein malnutrition, dysphagia, and parkinsonism. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition. Review of physician orders dated 08/27/25 to 10/18/25 revealed an order for puree texture food. 2. Review of the medical record for Resident #21 revealed an admission date of 01/25/24. Diagnoses included malnutrition, heart disease and osteoporosis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 00 indicating impaired cognition. Review of physician orders dated 08/27/25 to 10/16/25 revealed an order for puree texture food. 3. Review of the medical record for Resident #25 revealed an admission date of 07/24/25. Diagnoses included hemiplegia and hemiparesis, dysphagia, Alzheimer's disease, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of three indicating impaired cognition. Review of physician orders dated 09/17/25 to 01/14/26 revealed an order for puree texture food. 4. Review of the medical record for Resident #28 revealed an admission date of 10/02/24. Diagnoses included Parkinson's disease, malnutrition, heart disease, failure to thrive and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of one indicating impaired cognition. Review of physician orders dated 11/18/24 to 01/08/26 revealed an order for puree texture food. 5. Review of the medical record for Resident #42 revealed an admission date of 01/25/24. Diagnoses included Alzheimer's disease, malnutrition, dementia and vascular disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of two indicating impaired cognition. Review of physician orders dated 05/09/25 revealed an order for puree texture food. 6. Review of the medical record for Resident #52 revealed an admission date of 02/28/22. Diagnoses included dementia, malnutrition, pulmonary disease and vascular disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of five indicating impaired cognition. Review of physician orders dated 07/15/24 revealed an order for puree texture food. Observation and interview on 09/30/25 at 11:57 A.M. with Dietary Staff #144 revealed the facility had several residents that received puree diets. He began with three breaded salmon patties and added chicken broth with one spoonful at a time for a total of eight spoonfuls of broth in the roboku mixer. On three occasions Dietary Staff #144 wiped the sides of the roboku mixer with his gloved hand and then scraped the food on the glove on the edge of the mixer. Then with the same hand grabbed a jar of broth to add more liquid to the mixture (unmeasured). Several chunks were visualized on the sides of the mixer that were not fully mixed back in. The puree was completed and taste tested and found to have small chunks of salmon and breading. Dietary staff confirmed the mix had chunks and distinct pieces but stated it was the best they were going to get it. He confirmed they were looking for mashed potato consistency. Review of the facility policy titled Puree Diets dated 2022, revealed this diet was for residents who cannot chew or have difficulty swallowing. The sides of the blender shall be scraped and processed until smooth like pudding. This deficiency represents non-compliance investigated under Complaint Number 2661246.

Based on observations, interviews and facility policy review, the facility failed to ensure residents resided in a safe, clean and comfortable environment. This affected six residents (#3, #9, #27, #33, #41 and #50) of seven ( #21) reviewed for environmental concerns. The census was 59Findings Include:A facility tour conducted on 01/28/26 at 8:15 A.M. revealed all resident rooms, and the resident private dining room had a Packaged Terminal Air Conditioner (PTAC) unit (a self-contained heating and cooling unit in which offer individual room control ) . The temperature outside on this day was cold with daily highs in the mid to low teens and lows near or below zero Fahrenheit.Observation on 01/28/26 at 8:30 A.M. of the Resident Private Dining Room revealed the PTAC unit was installed below the room window. The unit was secured to the wall, however, on the right side of the unit there was a 1/4 inch opening between the PTAC unit and the wall where the unit did not span the opening leaving a gap opened to the outside which allowed cold air to come into the room.Observation conducted on 01/28/26 at 1:16 P.M. Resident 3's room revealed the PTAC unit was installed below the room window. The unit was secured to the wall, however, on the right side of the unit there was a 1/4 inch opening between the PTAC unit and the wall where the unit did not span the opening leaving a gap opened to the outside which allowed cold air to come into the room. This was verified by Licensed Practical Nurse (LPN) #175. Observation conducted on 01/28/26 at 1:20 P.M. of Resident # 33 room with Certified Nursing Assistant (CNA) #131 room revealed the PTAC unit was installed below the room window. he unit was secured to the wall, however, on the right side of the unit there was a 1/4 inch opening between the PTAC unit and the wall where the unit did not span the opening leaving a gap opened to the outside which allowed cold air to come into the room. CNA #131 confirmed the gap between the PTAC and the wall and the cold air coming into the room at the time of the observation. Observation conducted on 01/28/26 at 1:26 P.M. of Resident # 9 and Resident # 41 room revealed the PTAC unit was located under the window and not sealed around the entire unit . This was verified with Housekeeping Staff Member # 180 and confirmed that cold air was coming through the gap from the outside. Additionally on the right side of the unit from the top of the unit to the base board touching the floor , the wallpaper was peeling away from the wall (approximately 10 inches wide) exposing a dark substance all over the wall and the back of the wallpaper. Under the PTAC unit there was a white bath towel rolled up. Housekeeper #180 verified the black substance on the wall and wallpaper and the rolled up bath towel under the unit. Resident #9 stated during the observation that she can feel the cold air and explained the towel under the unit is used to soak up water that comes in from the outside elements. Resident #9 stated she had reported the problem several times to the administration with no results. Observation conducted on 01/28/26 at 1:30 P.M. of Resident # 27 room with Housekeeper #180 room revealed the PTAC unit was installed below the room window. The unit was secured to the wall, however, on the right side of the unit there was a 1/4 inch opening between the PTAC unit and the wall where the unit did not span the opening leaving a gap opened to the outside which allowed cold air to come into the room. The wood exposed to the outside appeared to be wet and black like it was damaged. Housekeeper #180 verified the findings at the time of the observation. Interview on 01/28/26 at 1:35 P.M. with the Maintenance Supervisor #100 revealed he was to go around the rooms and check if the PTAC units in each room allowed cold air into the facility and if so, he was to seal the areas with silicone. To his knowledge he was not aware of cold air coming through areas around the PTAC units.Interview on 01/29/26 at 8:47 A.M. With Resident #9 confirmed cold air is still coming into the room and the Maintenance Supervisor # 100 sealed the wallpaper to the wall. Resident #9 stated she was unhappy with the solution and was not asked if she wanted to change rooms to allow the PTAC unit to be serviced. Interview with the Administrator on 02/09/26 at 9:15 A.M. confirmed there were no Maintenance Work Order Request Forms for the PTAC units and for wallpaper coming away from the walls.Interview on 1/28/26 at 9:49 A.M. with the Maintenance Supervisor #100 confirmed he did check all the PTAC units in the resident rooms and sealed some of them. When asked what he did about the exposed black wall in Resident # 9 and Resident #42 room , he sealed the loose wallpaper to the wall . However, he did not prevent the cold air from coming into the room because the unit must be removed from the wall and from outside and installed correctly to prevent weather elements from coming into the room. Maintenance Supervisor confirmed the problem with the PTAC unit with Resident #9 and Residents #42 room was reported to him in the fall of 2025.Observation conducted on 02/09/26 at 1:55 P.M. of Resident # 50 room revealed PTAC unit was installed below the room window. The unit was secured to the wall, however, on the right side of the unit there was a 1/4 inch opening between the PTAC unit and the wall where the unit did not span the opening leaving a gap opened to the outside which allowed cold air to come into the room. The wallpaper on the right side of unit close to the floor baseboard is starting to peel away from the wall. This was verified by CNA #163. During the observation Resident # 50 stated, that is probably why I have bugs in my room.Review of the facility's , Maintenance Work order Request Form Completion Policy and Procedure not dated, revealed it is the policy of the facility to ensure a safe , functional, and comfortable environment for residents, staff and visitors through a standardized and efficient process for requesting, prioritizing, and completing maintenance work. All maintenance requests will be documented using the Maintenance Work Order Request Form. To ensure proper tracking, accountability, and timely resolution of issues.This deficiency represents non-compliance investigated under Complaint Number 2661246.

Based on medical record review, staff interview and policy review the facility failed to ensure proper indication of use for medication, and failed to ensure duplicate medication had maximum dosage for use indicated, this affected one resident (#36) of five reviewed for unnecessary medications. The facility also failed to ensure pain medications were ordered with parameters and administered appropriately. This affected two Residents (#10 and #36) of two reviewed for pain management. The census was 59. Findings Include: 1. Review of the medical record for Resident #36 revealed an admission date of 02/14/25. Diagnoses included dementia, cerebral infarct, fractured tibia, malnutrition, vascular disease and osteoporosis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 03 indicating impaired cognition. Review of physician orders dated 02/14/25 revealed an order for Acetaminophen (antipyretic/analgesic) tablet 325 milligram (mg) with instructions to give two tablets every four hours as needed for fever, an order for Acetaminophen tablet 325 mg with instructions to give two tablets every four hours as needed for pain. The physician orders did not include a maximum dosage for the Acetaminophen or a statement to not exceed a specific amount in 24 hours. The orders for the Acetaminophen 325 mg two tablets every four hours as needed for pain did not have parameters for use included. Review of physician orders dated 02/15/25 revealed an order for Ascorbic Acid (vitamin) tablet 500 mg with instructions to give one tablet once daily for sepsis, and Cholecalciferol (vitamin) Tablet 1000 unit with instructions to give one tablet once daily for sepsis. Review of physician orders dated 02/17/25 revealed there was an order for Norco (opioid) oral tablet 5/325 mg with instructions to give one tablet by mouth every eight hours as needed for pain. The orders for the Norco 5/325 mg oral tablet every four hours as needed for pain did not have parameters for use included. Review of the Medication Administration Report (MAR) dated 01/2026 revealed Acetaminophen tablets were given on 01/29/26 for a pain level of six and Norco tablet were given on 01/04/26 for pain level four, 01/06/26 for pain level of five, 01/07/26 for pain level of four, and 01/09/26 for pain level of four. Interview on 01/29/26 at 2:35 P.M. with Regional Nurse #178 confirmed two separate orders for pain medication (Acetaminophen and Norco). The regional nurse confirmed the order should have parameters so staff know when to administer which medication. Regional Nurse #178 confirmed Resident #36 had two separate orders for Acetaminophen one for fever reduction and the other for pain in their plan of care. The regional nurse confirmed the orders did not specify any parameters or daily safe maximum dosage of the medication. The regional nurse stated the orders would typically include a statement of a maximum amount, or that the resident should not exceed a certain dose. Regional Nurse #178 also confirmed sepsis was not an appropriate diagnosis for vitamins such as Ascorbic Acid and Cholecalcferol tablets. She confirmed the facility should ensure an appropriate diagnosis was documented for each medication used by the resident. 2. Review of the medical record for Resident #10 revealed an admission date of 04/17/23. Diagnoses included hemiplegia and hemiparesis, chronic obstructive pulmonary disease, diabetes, cerebral infarction, paralytic syndrome and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition. Review of physician orders dated 09/19/24 revealed an order for Acetaminophen tablet 500 mg with instructions to give two tablets every eight hours as needed for pain. The orders for the Acetaminophen 500 mg two tablets every eight hours as needed for pain did not have parameters for use included. Review of physician orders dated 04/01/25 revealed an order for Oxycodone HCL (opioid) oral tablet 5 mg with instructions to give one tablet by mouth every eight hours as needed for pain. The orders for the Oxycodone 5 mg one every eight hours as needed for pain did not have parameters for use included. Review of the Medication Administration Report (MAR) dated 01/2026 revealed Acetaminophen tablets were given once on 01/01/26 for a pain level of six, once on 01/11/26 for a pain level of three, twice on 01/13/26 for pain levels of six and four, once on 01/14/26 for pain level of eight, once on 01/16/26 for a pain level of eight, and once on 01/30/26 for a pain level of seven. The Oxycodone tablets were given twice on 01/01/26 for pain levels seven and six, twice on 01/02/26 for pain levels of five and four, twice on 01/03/26 for pain levels of four and four, once on 01/04/26 for pain level of four, twice on 01/06/26 for pain level of five and seven, once on 01/07/26 for a pain level of four, once on 01/08/26 for pain levels of seven, once on 01/09/26 for a pain scale of six once on 01/10/26 for pain levels of three, once on 01/11/26 for a pain scale of four and once on 01/12/26 for a pain level of four, twice on 01/13/26 for pain level of five and five, once on 01/15/26 for a pain level of eight, once on 01/16/26 for pain levels of four, once on 01/17/26 for a pain scale of four, once on 01/19/26 for pain level of one, once on 01/20/26 for a pain scale of seven, twice on 01/21/26 for pain levels of five and four, twice on 01/22/26 for pain levels of four and seven, once on 01/23/26 for a pain level of four, once on 01/24/26 for a pain level of four, once on 01/25/26 for pain levels of three, twice on 01/26/26 for pain scales of six and four, twice on 01/27/26 for pain levels of seven and seven, twice on 01/28/26 for pain scales of six and four, once on 01/29/26 for a pain level of seven, once on 01/30/26 for a pain level of four and once on 01/31/26 for a pain level of four. Review of the Medication Administration Report (MAR) dated 02/2026 revealed an Acetaminophen tablets was given on 02/08/26 for a pain level of five and Oxycodone tablets were given once on 02/01/26 for pain level four, twice on 02/02/26 for pain levels of six and four, twice on 02/03/26 for pain levels of six and eight, once on 02/04/26 for pain level of six, once on 02/05/26 for pain level of seven, once on 02/06/26 for a pain level of five, twice on 02/07/26 for pain levels of four and three, and twice on 02/08/26 for pain levels of five and four. Interviews on 02/09/25 from 11:00 A.M. to 1:00 P.M. with Regional Nurse #178 confirmed no pain medication parameters were put in place and also confirmed high pain scores of seven and eight were given Acetaminophen and scores of zero and three were given for Oxycodone. Review of the facility policy titled Pain Management undated, revealed the facility shall provide adequate management of pain to ensure residents attain or maintain the highest practicable well-being. When prescribing analgesics, the medical conditional shall be evaluated and determined the most appropriate therapy for pain. Chronic pain relief should begin with a low dose and titrate carefully until comfort was obtained.

Based on observation, staff interviews and record review, facility failed to ensure food was served and at a safe and palatable temperature. This had the potential to affect all facility residents except Resident #2. Facility census was 59. Findings include:Observation and interview on 09/30/25 at 12:25 P.M. with Dietary Staff (DS) #183 revealed food was being served to residents in the dining room and about half of the dining room had been served lunch. Dietary staff #183 was asked about food temperatures and DS #183 stated they took cooking temperatures but not holding temperatures. Temperatures were then obtained of food items on the hold steam table and found the green beans were 184 degrees Fahrenheit (F), the mashed potatoes were 178 degrees F, the burger patties were 120 degrees F, the salmon patties were 74 degrees F and the potatoes were 146 degrees F. The burger patties and salmon patties were placed back in the oven after surveyor intervention. DS #183 stated if the puree food had not taken so long, the food would not be outside the required temperatures. Interview on 09/30/25 at 12:40 P.M. with Kitchen Manager #141 stated the goal temperature for food held on the steam table was 150 degrees F. Observation and interview on 09/30/25 at 1:08 P.M. of test tray holding temperatures prior to making the test tray plate revealed the salmon patty holding temperature was 119.5 degrees F, the potatoes holding temperature was 106 degrees F, and the hold temperature of the green beans was 139 degrees F. The tray left the kitchen at 1:19 P.M. and was placed on a non-insulated cart and taken to the resident hall and at 1:30 P.M. after all trays were passed out to residents from the cart, the test tray had a temperature check performed and found the salmon patty was 106 degrees F, the potatoes were 96 degrees F and the green beans were 109 degrees F. The food tasted cold and the kitchen manager declined to taste the food and confirmed it would be cold. She confirmed they had plate warmers, but stated this particular hallway did not have a warming cart as the facility only had three insulated carts and only used a metal rack for this hallway. Review of the facility policy titled Holding Food Temperatures and Guidelines undated, revealed all food shall be held on the serving line at proper temperatures to promote optimum palatability, ensure food safety and prevent food [NAME] illness. Facility shall obtain serving line food temperatures at the beginning middle and end of the meal service. The temperature shall be palatable per resident preference and facility shall ensure they use methods to retain temperature of hot food items during meal service including a proper functioning steam table and heated plates. Hot foods should have a holding temperature of 135 or higher. This deficiency represents non-compliance investigated under Complaint Number 2661246.

Based on record review, observation, resident and staff interview, the facility failed to address resident concerns brought up at the resident council meetings. This affected four Residents (#23, #27, #30, and #44). Facility census was 59. Findings Include:1. Review of the medical record for Resident #23 revealed an admission date of 09/09/25. Diagnoses included atrial fibrillation, pulmonary disease, dysphagia and fracture of the right foot. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition. 2. Review of the medical record for Resident #27 revealed an admission date of 10/02/24. Diagnoses included dementia, pulmonary disease, dysphagia and heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 10 indicating impaired cognition. 3. Review of the medical record for Resident #30 revealed an admission date of 01/06/25. Diagnoses included memory deficit, chronic kidney disease and hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of eight indicating impaired cognition. 4. Review of the medical record for Resident #44 revealed an admission date of 04/05/24. Diagnoses included vascular disease, legal blindness, and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition. Review of the resident council meeting minutes from 01/27/25 through 01/28/26 revealed the residents voiced concerns about wanting a larger variety of snacks at the 02/22/25, 04/22/25, 05/23/25, 07/23/25 and 12/17/25 meetings. The residents also voiced concerns about food being delivered cold at the 01/27/25, 05/23/25, 07/23/25, 11/18/25, 12/17/25 and 01/28/26 meetings. Review of the facility provided concern forms revealed the following responses to the resident council concerns. Review of concern forms from 01/27/25 meeting revealed no mention of food temperature related concerns. Review of the concern form dated 02/27/25 revealed snacks are only ordered for the week on the nightly and would send fruit out if it was left over. Review of the concern form dated 04/24/25 revealed the variety of snack was addressed with We buy what is on the menu and will have different fruit in the next cycle. Review of the concern form dated 05/30/25 revealed facility was doing meal tray temperatures when the food got to the floor, and did not address the lack of variety of snacks. Review of the concern form dated 07/26/25 revealed the concern form did not address the lack of variety of snacks or the food temperatures being cold. Interviews on 09/30/25 at 10:50 A.M. with Residents # 23, #27, #30 and #44 who reported concerns with the variety of snacks and stated they have asked for more variety and options and facility does not follow up. They reported facility gives excuses why they need peanut butter sandwiches but that should not prevent them from offering additional options. Residents stated they have asked for variety of chips and fruit and have never been offered choices or a list of items that can be purchased by the supplier. The residents also reported concerns of the food being cold on a consistent basis. They confirmed food has been served cold in resident rooms as well as in the dining room. Review of the concern form dated 12/18/25 revealed concerns of cold food at dinnertime and residents were requesting more variety than pudding, jello, and peanut butter sandwiches. The plan included turning up the steam table to full temperature to see if this is the problem. It also stated facility had certain snacks on certain days and peanut butter sandwiches had to be provided every day for diabetic residents. Review of the resident council meeting minutes dated 01/28/26 revealed resident concerns of food arriving to their rooms cold. Interview on 01/29/26 at 4:22 P.M. with the Administrator revealed facility completed concern forms for concerns brought up in resident council meetings. Interview on 02/09/26 at 11:38 A.M. with Activity Director (AD) #108 revealed resident concerns get documented in the resident council minutes and revealed she then write up concern forms and provides them the appropriate department head to be reviewed and completed and should be returned to the Administrator for review and then finally returned to her for documentation purposes. AD #108 confirmed residents had consistent concerns related to the variety of snacks offered to the residents. She reported residents had memory care issues and may not remember the information they are reporting as a reason why this was consistently reported. She also denied knowledge of facility offering the variety residents had requested and reported the Kitchen Manager frequently came to the resident council meetings to hear concerns first-hand. AD #108 also acknowledged resident complaints of food temperature (cold food) were reported majority of months reviewed. She denied any knowledge of what facility was doing to make improvements and also denied any knowledge of test trays being completed and results reported to residents during the resident council meetings. AD #108 confirmed resident concerns should be taken seriously and addressed in a timely manner. AD #108 acknowledged there was a concern that the same issues were reported over and over again without consistent improvement. Review of the facility policy titled Resident Council Meetings undated, revealed residents shall have a structured forum to voice concerns. Administration shall respond in writing to concerns and recommendations raised by the resident council.

Based on medical record review, and staff interview, this facility failed to ensure an updated Preadmission Screening and Resident Review (PASARR) was completed when a resident was diagnosed with a new mental illness diagnosis. This affected one (Resident #53) of the one resident reviewed for accurate PASARRs. The facility census was 59. Findings include: Review of the medical record for Resident #53 revealed an admission date of 05/29/2020. Diagnoses included dementia, major depressive disorder, generalized anxiety, and delusional disorders. Review of Resident #53's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating an moderately impaired cognition for daily decision-making abilities. Review of the electronically uploaded PASARR dated 03/11/2020 revealed under question. Does this resident have a diagnosis of any mental disorders? This question was noted as no. Interview on 09/30/2025 at 2:13 P.M. with the Director of Nursing (DON) confirmed the PASARR was not updated and should have been with newly added mental illness diagnosis.

Based on record review and interviews, the facility failed to ensure the Quality Assurance meetings occurred quarterly as required. This had the potential to affect all residents who reside in the nursing facility. The census was 59.Findings include:Review of the Quality Assurance (QA) Meeting Notes for the Facility revealed the committee met on 10/15/24, 1/21/25, 4/15/25, and 7/22/25. There was no quarterly meetings held during the last quarter of 2025. The meeting documentation revealed this was the meeting the medical director participated in at the facility. Review of the facility records revealed the facility held monthly Quality Assurance Performance Improvement (QAPI) meetings, however the medical director did not participate in these meetings. Interview on 02/09/26 at 2:00 P.M. with the Interim Director of Nursing # 179 confirmed the facility does not have QA meeting notes to indicate a meeting was held in the last quarter of 2025. Interview on 02/09/26 at 4:00 P.M. with the Administrator and the Regional Clinical Director # 178, confirmed the Medical Director does not attend the QAPI meetings , he attends the QA meetings only, that are held quarterly.Review of the Facility's QAPI Plan dated 5/23/25 revealed the framework of QAPI included all the department managers, the administrator, the director of nursing, infection control nurse, medical director, consulting pharmacist who will provide QAPI leadership by being on the QAA committee. The QAA committee will meet monthly. The QAA committee will report all activities to the board of directors during their regular scheduled meetings. The administrator will report QAPI activities at the quarterly board of director's meetings. QAPI will be a standing agenda for these meetings. Input will be solicited from the board members on QAPI activities. All current projects and outcomes will be reviewed at the board meetings.

Based on observation and staff interview, the facility failed to ensure that the shower rooms were maintained in a clean and sanitary condition. This was noted in all four of the facility's shower rooms and impacted all residents who used them (Residents #1, #2, #3, #4, #5, #6, #7, #8, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #24, #25, #26, #27, #28, #29, #30, #31, #33, #34, #35, #36, #37, #39, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, and #54). The facility census was 54. Findings include: Observation on 11/14/24 at 8:55 A.M. revealed the 300's shower room contained black-spotted substances along the grout lines and tile, specifically at the bottom of the wall beneath the shower head and in the corners. Observation on 11/14/24 at 8:58 A.M. revealed the 100's shower room showed black-spotted substances along the grout lines and tile at the bottom of the wall under the shower head and in the corners. The shower chair had deteriorating fabric, with black-spotted substances and long, twisted hairs between the legs and base of the chair. Observation on 11/14/24 at 9:01 A.M. revealed the 200's hallway shower room had a black-spotted substance along the grout lines and tile, particularly at the bottom of the wall under the shower head and in the corners. Observation on 11/14/24 at 9:04 A.M. revealed the 400's hallway shower room had a black-spotted substance along the grout lines and tile, particularly at the bottom of the wall under the shower head and in the corners. Observation on 11/14/24 at 11:47 A.M. revealed the 300's hallway shower room had not been cleaned, with black-spotted substances along the grout lines and tile, and unknown black substances and hair on the shower chair. Observation on 11/14/24 at 11:54 A.M. revealed the 100's hallway shower room had not been cleaned, with black-spotted substances along the grout lines and tile. Observation on 11/14/24 at 12:01 P.M. revealed the 200's hallway shower room had not been cleaned, with black-spotted substances along the grout lines and tile. Observation on 11/14/24 at 12:04 P.M. revealed the 400's hallway shower room had not been cleaned, with black-spotted substances along the grout lines and tile. Observation on 11/14/24 between 3:01 P.M. and 3:15 P.M. revealed that the showers had remained uncleaned. Interview on 11/14/24 at 3:17 P.M. with Housekeeper #114 confirmed the shower areas should be cleaned weekly and as needed, Housekeeper #114 was unsure if it had been cleaned this week. The surveyor requested a log for evidence of staff cleaning the restroom as required; however, the facility was unable to provide documentation to confirm that cleaning had been completed weekly. Review of the shower cleaning policy, undated, revealed that shower grout should be cleaned weekly and as needed. This deficiency represents non-compliance investigated under Complaint Number OH00158584.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure wound care was completed per physician orders. This affected one (#10) of three residents reviewed for wound care. The facility census was 46. Findings Include: Review of resident #10's medical record revealed and admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side, cardiomyopathy, chronic systolic congestive heart failure, hypertension, osteoarthritis of knee, abnormalities of gait and mobility, weakness, and atrial fibrillation with long term use of anticoagulants. Resident #10 was discharged to the hospital on 12/08/23 per her request. Review of the discharge, return anticipated Minimum Data Set (MDS) assessment, dated 12/08/23, revealed Resident #10 had one facility acquired, unstageable pressure ulcer. Review of a Certified Nurse Practitioner (CNP) wound progress note, dated 08/08/23, revealed Resident #10 had a new right heel pressure wound, measuring 5.5 centimeters (cm) length by 7.5 cm width, with dark brown to black eschar covering the wound bed. Wound edges were pink and no wound drainage was noted. The note indicated the wound was caused by a brace/boot ordered by the orthopedic physician following an ankle fracture while out with family on 06/17/23. Review of Resident #10's right heel wound treatment orders revealed the following: From 08/08/23 to 09/09/23, apply clean dry dressing to the right heel then wrap with gauze at bedtime. From 08/09/23 to 11/27/23, apply Marathon (skin protectant) to right heel every 72 hours. From 09/13/23 to 10/11/23, cleanse right heal with normal saline, apply betadine to the edge and apply foam dressing every day. Do not wrap with Kerlix (gauze roll). From 10/12/23 to 11/15/23, cleanse with acetic acid then rinse, apply Santyl (debridement agent) ointment to the edge of the wound with Q-tip sparingly and cover with a foam dressing every night and as needed at bedtime. From 11/15/23 to 11/23/23, cleanse with acetic acid then rinse, apply Santyl ointment to the edge of the wound with a Q-tip sparingly and cover with a foam dressing twice daily and as needed. Beginning 11/23/23, cleanse with Dakin's 1/4 strength, apply Santyl ointment and cover with saline moistened gauze, NOT soaked, and secure with a dry dressing every day and as needed. Review of the Treatment Administration Records (TAR) from October 2023 and November 2023 revealed Resident #10 did not receive the ordered right heel wound treatment on 10/13/23, 11/01/23, 11/08/23, 11/10/23, the evening treatment on 11/16/20 and the morning treatment on 11/22/23. Further review revealed Resident #10 did not receive the Marathon treatment to the right heel on 10/11/23, 11/10/23 and 11/16/23. Review of nursing progress notes from October 2023 through November 2023 revealed no documentation Resident #10 refused wound care treatments on the dates identified on the TAR as not completed. Additionally, there was no documentation indicating why treatments had not been completed as ordered. Interview on 01/04/24 at 1:45 P.M. with Licensed Practical Nurse (LPN) #333 verified Resident #10's right heal wound treatments were not completed as ordered on 10/11/23, 10/13/23, 11/01/23, 11/08/23, 11/10/23, 11/16/23, and 11/22/23. Review of facility policy titled Delaware Court Skin Care Policy, undated, revealed the facility will provide comprehensive assessment and care to skin in an effort to prevent and/or treat skin breakdown through a process of identification, daily monitoring, treatment, and re-evaluation that is based on the resident's individual assessment. Additionally, for treatment, nursing will follow the Delaware Court Wound Care protocols with the physician's approval or a treatment regimen as directed by the physician. This deficiency represents non-compliance investigated under Complaint Number OH00149221.

Based on Board of Executives of Long-Term Services and Supports (BELTS) website review review and staff interview, and BELTS Representative interview, the facility failed to ensure the Administrator had an active license. This affected all 52 residents in the facility during the annual survey. The census was 52. Findings include: Review of the Board of Executives of Long-Term Services and Supports (BELTS) website on [DATE] revealed the facility's Administrator's license had expired on [DATE]. Interview on [DATE] at 11:55 A.M., with the Administrator revealed he was unaware his license had expired until surveyor notification during the annual survey. Interview on [DATE] at 11:30 A.M., with the Board of Executives of Long-Term Services and Supports Representative confirmed the Administrator had been practicing for six months with an expired license and would be receiving disciplinary action from the board. She revealed the Administrator did not apply for renewal of licensing until [DATE].

Based on observation and staff interviews, the facility failed to ensure the plumbing equipment was maintained in a safe and sanitary conditions . This had the potential to affect 50 of 50 residents who receive meals from the kitchen. excluding two (#3 and #305) residents who recive tube feeding. The faciltiy census was 52. Findings include: Tour of the kitchen on 10/16/23 at 9:30 A.M., revealed a red plastic coffee can under the three compartments sink on the right side. The pipe had a slow drip. Observations on 10/18/23 from 11:18 A.M. to 11:45 A.M., while observing puree food preparation, the kitchen floor became flooded, instantly water appeared from the floor under the three compartments sink to the far right under the oven and to the far left of the walk in freezer. The water was approximately one quarter inch deep. Employees were observed walking through the water unaware of how the water appeared. Observation of the area under the three compartment sink revealed the drain and tiles around it under the sink were raised. No water was draining into the drain. The red plastic coffee can to the right of the sink was full of dark brown water. Dietary Aide #138 removed the plastic can and emptied it. Dietary Manager #122 placed three white blankets on the floor to soak up the water. Attempts to locate the maintenance manager failed. The Administrator arrived and assessed the situation. Interview at the time of the observation, with the Administrator and Dietary Manager #122 verified there was water backed up from the walk in freezer, under the three compartment sink, under the clean workstation in the middle of the kitchen and to the far right under the oven and gas stove.

Based on record review, policy review and staff interviews, the facility failed to ensure an infection surveillance plan was in place for identifying, tracking, and monitoring outbreaks. This had the potential to affect all 52 residents. Facility census was 52. Findings include: Review of the infection control tracking logs revealed resident infections were monitored for location with a facility map, but signs symptoms, labs and cultures were not included. There was no evidence of the use of evidence-based surveillance criteria to define infections and determine appropriateness of treatment options. There was no evidence the facility determined percentage of nosocomial (community based infections) for facility each month as a tracking tool. There was no evidence that notes, cultures, labs, treatments and multi-drug-resistant organism statuses were tracked upon transfer to and from acute care hospitals. Interview on 10/19/23 at 12:25 P.M., with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #127 revealed if a resident has signs of infection they will talk with the physician and begin an antibiotic and monitor residents with close contacts to that individual and if they have similar symptoms they will begin the same treatment. Interview on 10/19/23 at 3:00 P.M., with DON and LPN #127 revealed they have sections of their infection control tracking logs not completed such as percentage of infection, the organism, signs and symptoms, labs and cultures. Review of the policy titled, infection Control Policy and Procedure dated 11/20/17 revealed the facility would maintain and infection control program to prevent development and transmission of disease and infection. The policy revealed the facility would monitor nosocomial and community acquired infections and their manner of spreading. The facility shall keep a log with the dates of the infection, causative agent, origin site and describe cautionary measures taken to prevent spread.

Based on record review, staff interview, email communication review and policy review, the facility failed to ensure antibiotics were ordered and used appropriately for residents with potential infections. This affected four (#21, #35, #37, #47) of four residents reviewed for antibiotic stewardship. Facility census was 52. Findings include: 1. Review of the medical record for the Resident #21 revealed an admitted [DATE]. Diagnoses included end stage renal disease, diabetes, anxiety, blindness, and hypothyroidism. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was cognitively intact and required extensive assistance of two staff members for bed mobility and was totally dependent for transfers. Review of the plan of care revealed no mention of infection or treatment of infection, besides COVID infections. Review of the physician order dated 08/10/23 revealed orders for wound care to cleanse right leg with warm soapy water and use 0.9 normal saline flush over, apply wound gel and cover with foam dressing. Order dated 08/15/23 revealed order for Meropenem Intravenous solution reconstituted 500 milligram (mg) with instructions to be given in the afternoon for infection until 08/19/23. On 09/09/23, Resident #21 had order for doxycycline hyclate tablet 100 mg to be given twice daily for left lower extremity wound for seven days. Review of progress note dated 09/09/23 revealed upon arrival from dialysis, the emergency medical technicians that provided transport revealed the resident had an open area that looked infected. The area was the right lateral lower extremity and was warm to touch and had green oozing fluid coming from wound. New orders in place for wound care and antibiotic. Review of the infection log for August 2023 revealed Resident #21 had right leg cellulitis identified on 08/17/23. Review of the infection log for September 2023 revealed Resident #21 had a left lower extremity wound identified on 09/09/23 and cellulitis identified on 09/28/23. There was no evidence of McGreer's or any other evidence based practice assessment completed to determine appropriate course of action for Resident #21. There was no evidence of laboratory results, cultures and sensitivities that were completed. Interview on 10/19/23 at 12:25 P.M., with DON and Licensed Practical Nurse (LPN) #127 revealed they use the McGreer's assessment but only for urinary tract infections and only if they complete urinalysis. They revealed facility did not use any assessment or check list to determine appropriateness of antibiotics and revealed they tray to get cultures and sensitivities for other infections. DON revealed if they had a resident get an infection (ie) pneumonia and another resident nearby or has had contact with the infected resident, they will ask the doctor to start the same antibiotics as the primary resident was receiving. They revealed at times dialysis or hospice will initiate antibiotics and they do not have a process to follow those for appropriateness of treatment. Interview on 10/19/23 at 3:00 P.M., with DON and LPN #127 revealed they wound need to look for evidence of labs, cultures and sensitivities and McGreer's as they only could find at time McGreer's from 2020 and 2021. DON and LPN #127 acknowledged the importance of antibiotic stewardship to ensure residents get timely and appropriate treatment and prevent residents from developing resistance to certain antibiotics and infections for the future. Review of an email communication dated 10/20/23 at 4:01 P.M., from the Director of Nursing (DON) revealed resident #21 had chronic cellulitis. On 09/09/23, she was prescribed Doxycycline 100 mg for left lower extremity wound infection, with signs and symptoms of redness, warm to touch, and scant drainage. On 09/28/23, the resident received prescription for Bactrim DS 800/160 mg for cellulitis of right toe which was recommended by the dialysis provider. 2. Review of the medical record for the Resident #35 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, nontoxic single thyroid nodule, paroxysmal atrial fibrillation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively impaired and required assistance of two staff and assist with toileting. Resident was incontinent of bowel and bladder. Review of the plan of care revealed no mention of infection or treatment of infection. Review of physician orders for 09/18/23 revealed a urinalysis with culture and sensitivity was ordered due to pain, and increased frequency in urination. Order dated 09/19/23 for Macrobid oral capsule (nitrofurantoin Monohyd Macro) 100 mg with instructions to give one capsule by mouth daily for urinary tract infection (UTI) for seven days. Orders dated 09/25/23 for Ceftin 250 mg twice daily for seven days and pyridium three time daily for three days. Review of the progress notes dated 09/19/23 revealed staff received laboratory results from urinalysis for Resident #35 and sent to the certified nurse practitioner (CNP). Received order to begin Macrobid 100 mg by mouth twice a day for 14 doses for signs and symptoms pending culture and sensitivity at this time. Progress note dated 09/25/23 revealed CNP was notified of results of the culture and sensitivity. Resident continued to have burning upon urination, increased frequency and increased irritability. New orders for ceftin and pyridium provided by CNP and pyridium not yet available. Review of the infection log for September 2023 revealed Resident #35 had a urinary tract infection (UTI) identified on 09/19/23, and a UTI identified on 09/25/23. There was no evidence of McGreer's or any other evidence based practice assessment were completed to determine appropriate course of action for Resident #35. There was no evidence of laboratory results, cultures and sensitivities that were completed. Review of an email communication dated 10/20/23 at 4:01 P.M., from DON revealed resident #35 had chronic cellulitis. On 09/19/23 she complained of burning and frequency. DON mentioned McGreer's noted a UTI and laboratory result was positive for UTI and culture/sensitivity was positive with prescription for Macrobid. On 09/25/23 the Macrobid was discontinued and cefuroxime was ordered for better susceptibility. 3. Review of the medical record for the Resident #37 revealed an admitted [DATE]. Diagnoses included aftercare for joint replacement and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was cognitively impaired and required extensive assistance of one staff members to was totally dependent. Resident was incontinent of bowel and bladder and had no skin issues. Review of the plan of care revealed no mention of infection or treatment of infection. Review of physician orders for 09/09/23 to 09/15/23 for Macrobid oral capsule (nitrofurantoin Monohyd Macro) 100 mg, with instructions to give one capsule by mouth daily for UTI for seven days. Order dated 09/13/23, for Bactrim DS oral tablet 800-160 mg (sulfamethoxazole-trimethoprim) with instructions to give one tablet twice daily for 14 days (28 total doses). Order dated 09/15/23 for Keflex oral capsule 500 MG (cephalexin) with instructions to give one capsule by mouth four times daily for infection. Review of the progress notes dated 09/07/23 revealed Resident #37 was complaining of pain in peri area with urination. Order for a urinalysis with culture and sensitivity obtained to be sent to laboratory. Note dated 09/13/23 revealed outpatient surgery follow-up provider ordered Bactrim for wound under stomach area and a later note revealed system identified a possible drug allergy for Bactrim. Progress note dated 09/15/23 revealed resident continued antibiotics for right hip infection. Review of the infection log for September 2023 revealed Resident #37 had a urinary tract infection (UTI) identified on 09/09/23, a bacterial infection identified on 09/13/23 and a bacterial infection identified on 09/14/23. There was no evidence of McGreer's or any other evidence based practice assessment were completed to determine appropriate course of action for Resident #37. There was no evidence of laboratory results, cultures and sensitivities that were completed. Review of emailed communication dated 10/20/23 at 4:01 P.M., from DON revealed Resident #37 had a history of aseptic necrosis of right femur after joint replacement a with a hip revision. On 09/09/23 resident had a fever with complaints of dysuria. McGreer's was positive and urinalysis was positive and culture and sensitivity was positive. A prescription for Macrobid was given for UTI. On 09/13/23 resident went to outpatient appointment with the joint revision surgeon who noticed an area starting to get an infection evidenced by pain, redness and warmth. Bactrim was ordered and was found to have an allergy and antibiotic was changed to Keflex. 4. Review of the medical record for the Resident #47 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following intracerebral hemorrhage affecting right dominant side, aphagia following non traumatic intracerebral hemorrhage, atrial fibrillation, need for assistance with personal care and attention to gastrostomy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was cognitively impaired and required extensive assistance to total dependence. Resident was incontinence of urine and bowel and had no skin issues. Review of the plan of care revealed no mention of infections or treating infections. Review of physician orders dated 08/30/23 identified orders for Ciprofloxacin HCl tablet 500 mg with instruction to give one tablet twice daily for infection/UTI for seven days (14 doses) Review of the progress notes dated 08/27/23 revealed at 3:00 A.M., the resident was seen moaning and rubbing stomach area with left hand. Resident was assessed and given a docusate sodium. At 4:00 A.M., resident reported stomach was still hurting Zofran given. At 5:00 A.M., resident moaning on occasion, Tylenol given for 4/10 pain with partially effectiveness at 6:00 A.M. with pain down to 2/10. Note at 7:45 A.M., revealed resident was screaming in pain abdomen distended and tender to touch. Resident had large bowel movement at 7:30 A.M. Nurse contacted emergency serves for transport to hospital and resident left facility at 8:15 A.M. Note at 11:49 A.M. revealed hospital contacted nursing staff informed resident to be admitted for urolithiasis. Review of the infection log for August 2023 revealed Resident #47 had a urinary tract infection (UTI) identified on 08/30/23. There was no evidence of McGreer's or any other evidence based practice assessment were completed to determine appropriate course of action for Resident #47. There was no evidence of laboratory results, cultures and sensitivities that were completed. Review of emailed communication dated 10/20/23 at 4:01 P.M., from DON revealed Resident #47 was sent to the hospital on 08/23/23 and found to have a urinary tract infection with renal stones and renal mass. On 08/27/23, he was sent to the hospital for abdominal distension and pain and returned with diagnosis on urolithiasis with no antibiotics ordered. On 08/31/23, sent to hospital with pain and nausea and vomiting with diagnosis of cystitis and was given a prescription for cipro for pseudomonal UTI and ureterolithiasis. Review of the policy titled, Infection Control Policy and Procedure dated 11/20/17 revealed facility would maintain an infection control program to prevent development and transmission of disease and infection. The policy did not include any language of using McGreer's or another evidence based practice assessment or check off to ensure treatments are appropriate and the correct antibiotic was initiated timely.

Based on financial records, Personal Needs Account Procedures review and staff interviews the facility failed to ensure resident care needs account was in an interest-bearing account. In addition, none of the 12 residents or their representatives signed an authorization form for the facility to handle their personal care need accounts. This affected all 12 (#36, #11, #5, #29, #7, #15, #14, #13, #42, #44, #34 and #33) residents personal care need accounts which the facility is representative payee. The census was 52. Findings include: Review of Resident #36, #11 and #7's monthly bank statements for their personal care needs account revealed the accounts are in a checking account with a local bank. The account does not bear any interest. Interview on 10/16/23 at 2:30 P.M., with Business Office Manager #159 confirmed all 12 personal care need accounts (#36, #11, #5, #29, #7, #15, #14, #13, #42, #44, #34 and #33) are at the local bank, in a checking account that does not bear interest. She confirmed she does not have a personal care need account authorization form signed by each resident or their representatives. Interview on 10/17/23 at 9:00 A.M., with the Administrator confirmed the 12 resident accounts that they are payee representatives for are in a checking account and was unaware the accounts were not bearing interest. Review of the undated procedure titled Personal Needs Account Procedures, revealed no information about interest bearing accounts.

Based on financial record reviews, resident interviews and staff interviews, the facility failed to ensure residents receive a quarterly statement for their personal care need account. This affected 12 (#36, #11, #5, #29, #7, #15, #14, #13, #42, #44, #34 and #33) of 12 residents with personal care need accounts. The census was 52. Findings include: Interview on 10/15/23 from 10:00 A.M. to 10:15 A.M., with with Resident #13 and Resident #14 revealed they do not receive a statement for her personal care need account. Review of the excel sheet from 10/23/22 to 10/03/23 for Resident #7, #11, #33, #36, and #44 revealed it is not an official statement for the personal care need account or a bank statement for each resident. The excel sheet does not have the resident's name or account number, or interest earned on it. Interview on 10/16/23 at 2:30 P.M., with Business Office Manager #159 confirmed the facility receives monthly checking account statements for Resident (#36, #11, #5, #29, #7, #15, #14, #13, #42, #44, #34 and #33) personal care needs accounts and the statements are filed in the business office. Business Office Manager #159 stated the statements are reviewed and transforms the information from the bank statement onto an excel sheet for easy review. Business Office Manager #159 stated she gives the resident a copy of the excel sheets every two months.

Based on observations, medical record reviews, dentist roster review, Dental Mobile Office Representative interview, resident interview and staff interviews, the facility failed to offer dental services to residents. This affected one (#13) of one resident reviewed for dental services. This had the potential to affect 20 (#1, #3, #5, #36, #8, #10, #11, #13, #14, #15, #16, #17, #22, #24, #26, #27, #29, #34, #36, #42 and #46) additional resident who consented to see the dentist. The census was 52. Findings include: Review of the medical record for the Resident #13 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease , chronic pulmonary edema, and chronic respiratory failure with hypoxia. Resident #13 obtained Medicaid benefits on 10/06/22 . Observation on 10/16/23 at 3:34 P.M., with Resident #13 revealed she is without teeth and without dentures. Interview at the time of the observation revealed Resident #13 revealed she would like to have dentures. She requested them in the past and no one has spoken to her about seeing a dentist. Interview on 10/17/23 at 11:00 A.M., with the Social Service Designee #120 revealed the dentist services had not been in the building for at least a year. Social Service Designee #120 reported the dentist office has not contacted her with details of a visit for the residents and denied contacting the dental office herself. Interview on 10/18/23 at 11:03 A.M., with the Dental Mobile Office Representative #500 revealed the last visit to the facility was 09/19/22 and are due to come in for this year's visit. A visit has not been arranged because the facility failed to submit an updated resident roster that was requested on 04/16/23, 08/09/23 and 08/17/23. This request would determine how many residents to see on the next scheduled visit. The representative stated it is the designated facility staff member's responsibility to notify the practice of any new patients and any immediate dental services. Review of Resident #13's medical record revealed dental services were not offered to Resident #13 until after surveyor intervention. Consent to see the dentist was signed on 10/18/23. Review of the dentist roster list for 03/31/23 revealed 20 (#1, #3, #5, #36, #8, #10, #11, #14, #15, #16, #17, #22, #24, #26, #27, #29, #34, #36, #42 and #46) residents were waiting to see the dentist. Resident #13 was not on the list. Interviews on 10/16/23 from 10:15 A.M. to 10:45 A.M., with Resident #14 and #27 denied seeing the dentist in the past year.

Based on financial record reviews and staff interview, the facility failed to ensure residents who are insured by Medicaid do not exceed $2,000.00 in their personal care needs accounts. This affected three Medicaid residents (#7, #11 and #36) of three accounts reviewed with funds above the $2,000.00 limit. The census was 52. Findings include: Review of Resident #7's Checking Account Bank Statement and excel sheet revealed a balance of $5,140.52 as of 10/11/23. A notification of spend letter was not available. Review of Resident #11's Checking Account Bank Statement and excel sheet revealed a balance of $4,008.79. as of 10/11/23. A notification of spend letter was not available. Review of Resident #36's Checking Account Bank Statement and excel sheet revealed a balance of $4,777.46 as of 10/3/23. A Spin Down notification letter was sent to Resident #36 representative on 04/05/23. Interview on 10/16/23 at 2:30 P.M., with Business Office Manager #159 stated the families or guardians have been notified of the account balances, however, the balances remain above the Medicaid amount. She was not aware Residents #7, #11 and #36 could be ineligible for their Medicaid benefits because of their account balances for Resident #7 and #11.

Based on record review, policy review and staff interview, the facility failed to ensure a residents code status was accurately reflected in the medical record. This affected one (#10) of two residents reviewed for advanced directives. The facility census was 52. Findings include Review of the medical record for the Resident #10 revealed an admitted [DATE]. Diagnoses included chronic atrial fibrillation, cerebral infarction, cognitive deficit, and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively impaired with a BIMS of 3 and required extensive assistance of one to two staff members for bed mobility and transfers. Review of the code status sheet signed by the physician dated 03/02/18 revealed Resident #10 was code status DNRCC-A. This was documented in the paper medical record. Review of physician orders dated 03/14/22 identified orders for resident code status of DNRCC in the electronic medical record. Review of the plan of care dated 04/05/23 revealed Resident #10 had a code status of DNRCC-Arrest which includes providing care up until the point of a cardiac arrest. Interview on 10/16/23 at 5:47 P.M., with the Director of Nursing (DON) confirmed Resident #10's electronic medical record had DNRCC listed as active code status. DON also confirmed Resident #10's paper chart had DNRCC-A listed as the code status and included the signed DNR paperwork from the physician stating code status was DNRCC-A. DON reviewed paper record and electronic record and revealed it switched some time from March 2022 to September 2022 according to the documentation and mention in notes, orders, and care conferences. Review of the undated policy titled, Advanced Directives, revealed advanced directives were legal documents to protect the rights of the residents. The policy revealed the chart would include evidence of code status if they were on file.