Every finding on record at Willowbrooke Court Skilled Center at Manor House

Based on observation and interview it was determined that the facility failed to ensure food was stored, prepared, and served in a manner that prevents food borne illness to the residents. 6/3/26 10:22 AM - During a tour of the kitchen, a heavy build up of dust clumps was present on the wall adjacent to a food prep table and the ice machine. The air filters of the ice machine were covered in a thick layer of dust. 6/3/26 10:24 AM - Findings were reviewd with E5 (DOC/N) during the kitchen tour. 6/5/26 12:30 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 (R8) out of six reviewed for Resident Assessments, the facility failed to assess R8 no less than once every three months. Findings include: Review of R8's clinical record revealed: 10/1/24 - R8 was admitted to the facility. 10/7/24 - An admission MDS was completed for R8. 12/27/24 - A significant change MDS was completed for R8. 3/26/25 - A quarterly MDS was noted to be in progress for R8. As of 5/5/25, it was not completed. 5/5/25 10:10 AM - An interview with E2 (DON) confirmed that the quarterly MDS was still in progress and was overdue by 38 days. E2 stated that during the dates 3/26/25 to 4/21/25 no qualified staff was working that was able to complete the MDS. Additionally, E2 stated that the MDS would be completed by 5/7/25 as the MDS coordinator (E12) was back from leave and working on it. 5/6/25 2:00 PM - Findings discussed with E1, E2 (DON), E3 (ADON), and E5 (ED) at exit conference.

Based on interview and record review, it was determined that for one (R8) out of five residents sampled for medication review, the facility failed to develop a comprehensive care plan for insomnia. Findings include: Review of R8's clinical record revealed: 10/1/24 - R8 was admitted to the facility including a diagnosis of insomnia. 10/1/24 - A physician's order was written for melatonin oral tablet 10 mg: give one tablet by mouth every twenty four hours as needed for insomnia. January 2025 - The MAR documented that R8 received several doses of melatonin. 5/5/25 3:02 PM - An interview with E13 (RN) confirmed that she would attempt non-pharmacological interventions per the care plan. Additionally, E13 acknowledged that R8 did not have a care plan addressing insomnia during that timeframe. The facility lacked evidence of developing a care plan with goals and interventions related to insomnia. 5/6/25 2:00 PM - Findings discussed with E1, E2 (DON), E3 (ADON), and E5 (ED) at exit conference.

Based on record review and interview, it was determined that for three (R5, R7, and R8) out of six sampled residents, the facility failed to have input from all required interdisciplinary team (IDT) members at the residents' care plan meetings. Findings include: 1. Review of R5's clinical record revealed: 5/18/23 - R5 was admitted to the facility. 9/4/24 - A quarterly MDS assessment was completed for R5. 9/16/24 - A care plan meeting note lacked evidence of CNA and physician input. 12/4/24 - A quarterly MDS assessment was completed for R5. 12/10/24 - A care plan meeting note lacked evidence of CNA and physician input. 3/4/25 - A quarterly MDS assessment was completed for R5. 3/10/25 - A care plan meeting note lacked evidence of CNA and physician input. 5/5/25 12:45 PM - An interview with E4 (SW) confirmed that a CNA is always invited to care plan meetings and if they are not able to attend she tries to include CNA input in the meeting. E4 was unable to provide evidence of CNA input in the aforementioned meeting dates. 5/5/25 1:00 PM - An interview with E1 (NHA) revealed that the physician visits should correlate with the care plan meetings and the meeting notes should reflect any concerns presented in the physician's progress notes. A review of the aforementioned care plan meetings and physician progress notes revealed that physician's visits did not occur prior to the care plan meeting. The care plan meeting notes lacked evidence that the physician provided input. 5/6/25 11:30 AM - During an interview, E1 confirmed that the physician's progress notes did not correlate with the care plan meeting notes. 2. Review of R7's clinical record revealed: 8/16/24 - R7 was admitted to the facility. 9/25/24 - A significant change MDS was completed for R7. 10/1/24 - A care plan meeting note lacked evidence of CNA and physician input. 11/25/24 - A significant change MDS was completed for R7. 12/3/24 - A care plan meeting note lacked evidence of CNA and physician input. 2/19/25 - A quarterly MDS assessment was completed for R7. 2/25/25 - A care plan meeting note lacked evidence of CNA and physician input. 5/5/25 12:45 PM - An interview with E4 (SW) confirmed that a CNA is always invited to care plan meetings and if they are not able to attend she tries to include CNA input in the meeting. E4 was unable to provide evidence of CNA input in the aforementioned meeting dates. 5/5/25 1:00 PM - An interview with E1 (NHA) revealed that the physician visits should correlate with the care plan meetings and the meeting notes should reflect any concerns presented in the physician's progress notes. A review of the aforementioned care plan meetings and physician progress notes revealed that physician's visits did not occur prior to the care plan meeting. The care plan meeting notes lacked evidence that the physician provided input. 5/6/25 11:30 AM - During an interview, E1 confirmed that the physician's progress notes did not correlate with the care plan meeting notes. 3. Review of R8's clinical record revealed: 10/1/24 - R8 was admitted to the facility. 10/7/24 - An admission MDS was completed for R8. 10/15/24 - A care plan meeting note lacked evidence of CNA and physician input. 12/7/24 - A significant change MDS was completed for R8. 1/7/25 - A care plan meeting note lacked evidence of CNA and physician input. 3/26/25 - A quarterly MDS assessment was in progress for R8. 4/1/25 - A care plan meeting note lacked evidence of CNA and physician input. 5/5/25 12:45 PM - An interview with E4 (SW) confirmed that a CNA is always invited to care plan meetings and if they are not able to attend she tries to include CNA input in the meeting. E4 was unable to provide evidence of CNA input in the aforementioned meeting dates. 5/5/25 1:00 PM - An interview with E1 (NHA) revealed that the physician visits should correlate with the care plan meetings and the meeting notes should reflect any concerns presented in the physician's progress notes. A review of the aforementioned care plan meetings and physician progress notes revealed that physician's visits did not occur prior to the care plan meeting. The care plan meeting notes lacked evidence that the physician provided input. 5/6/25 11:30 AM - During an interview, E1 confirmed that the physician's progress notes did not correlate with the care plan meeting notes. 5/6/25 2:00 PM - Findings discussed with E1, E2 (DON), E3 (ADON), and E5 (ED) at exit conference.

Based on record review and interview, it was determined that for three (R1, R7, and R114) out of twelve residents reviewed for care plans, the facility failed to meet professional standards of the Delaware Board of Nursing Scope of Practice by having LPNs complete admission assessments and admission or progress notes. Findings include: Delaware State Board of Nursing - RN, LPN and NA/UAP Duties 2023 . Admission Assessments * - RN . *= Once a care plan is established, the LPN may do assessments . 1. Review of R1's clinical record revealed: 5/1/24 - R1 was admitted to the facility. 5/2/24 - A review of R1's admission assessments revealed that a bowel and bladder assessment, functional abilities assessment, wandering risk, and skilled evaluation assessment were completed by E4 (LPN). 6/3/24 12:10 PM - An interview with E4 confirmed that the nurse assigned to a new admission resident is responsible to complete the admission assessments and progress note. E4 confirmed there are fourteen admission assessments to be completed. E4 confirmed she completed admission assessments for R1 on 5/2/24. 2. Review of R7's clinical record revealed: 5/10/24 - R7 was admitted to the facility. 5/10/24 - A review of R7's admission assessments revealed that the long term care evaluation, functional abilities assessment, side rail assessment, and Covid-19 admission screening were completed by E4 (LPN). 6/3/24 12:10 PM - An interview with E4 confirmed she completed admission assessments for R7 on 5/10/24. 3. Review of R114's clinical record revealed: 5/23/24 - R114 was admitted to the facility. 5/24/24 - A review of R114's admission assessment revealed that the admission progress note, wandering risk assessment, long term care evaluation, and the functional abilities assessment were completed by E4 (LPN). 6/3/24 12:10 PM - An interview with E4 confirmed she completed admission assessments for R114 on 5/10/24. 6/3/24 2:00 PM - Findings were reviewed with E1 (NHA), E2 (ED), and E3 (Corporate) during the exit conference.

Based on record review and interview it was determined that for three (R1, R4, and R7) out of five residents reviewed for medication review, the facility failed to ensure adequate monitoring of adverse effects. Findings include: 1. Review of R1's clinical record revealed: 5/1/24 - R1 was admitted to the facility. 5/1/24 - A physician's order was written for apixaban oral tablet 2.5 mg (anticoagulant) give one tablet by mouth two times a day for atrial fibrillation. 5/2/24 - A care plan revealed that R1 was on anticoagulant therapy related to atrial fibrillation (heart condition) and interventions included but not limited to administer my anticoagulant medications as ordered by my physician. Monitor me (R1) for side effects and effectiveness every shift. 5/31/24 - A review of R1's medical record revealed no evidence of monitoring for side effects related to anti-coagulant use. 6/3/24 10:55 AM - An interview with E1 (NHA) confirmed that facility did not have monitoring in place related to R1's use of anticoagulants. 2. Review of R4's clinical record revealed: 5/18/23 - R4 was admitted to the facility. 5/19/23 - A care plan revealed that R4 was on an anticoagulant for atrial fibrillation (heart condition) and interventions included but not limited to monitor me (R4) and document/report any adverse reactions of my anticoagulant therapy 7/14/23 - A physician's order was written for Eliquis (anticoagulant) oral tablet 5mg give one tablet two times a day for paroxysmal atrial fibrillation (heart condition). 5/30/24 - A review of R4's medical record revealed no evidence of monitoring for side effects related to anti-coagulant use. 6/03/24 10:55 AM - An interview with E1 (NHA) confirmed that facility did not have monitoring in place related to R1's use of anticoagulants. 3. Review of R7's clinical record revealed: 5/10/24 - R7 was admitted to the facility. 5/12/24 - A care plan revealed that R7 was on anticoagulant therapy related to clot prevention and interventions included but not limited to monitor me (R7) and document/report any adverse reactions of my anticoagulant therapy 5/12/24 10:45 AM - A physician's order was written Lovenox injection (anticoagulant) prefilled syringe solution 3mg/ 0.3mL: inject one dose subcutaneously every evening shift for prevention of blood clotting. 5/31/24 - A review of R7's medical record revealed no evidence of monitoring for side effects related to anti-coagulant use. 6/3/24 10:55 AM - An interview with E1 (NHA) confirmed that facility did not have monitoring in place related to R7's use of anticoagulants. 6/3/24 2:00 PM - Findings were reviewed with E1 (NHA), E2 (ED), and E3 (Corporate) during the exit conference.

Based on observation, interview and record review, it was determined that for R8, the facility failed to treat R8 with dignity and respect. Findings include: 5/1/21 - R8 was admitted to the facility. 6/7/23 - A quarterly MDS assessment documented that R8 was cognitively impaired and occasionally incontinent of bladder. 6/15/23 9:53 AM - During an observation, a staff member was pushing R8 down the hallway in her wheelchair. E5 (LEA) stated loudly that the resident had peed on herself so that other residents and/or visitors could hear what was said. 6/15/23 10:39 AM - During an interview, E5 confirmed that the facility failed to provide a dignified existence when she loudly expressed R8's personal care needs in a common area. 6/21/23 12:20 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E4 (ED) at the exit conference.

Based on record review, interviews and review of facility documentation, it was determined that for one (R9) out of five residents reviewed for unnecessary medications, the facility failed to limit an as needed (PRN) psychotropic medication to 14 days. Findings include: Review of R9's medical record revealed: 5/18/23 - R9 was admitted to the facility. 5/18/23 - R9 had a Physician's order for Alprazolam tablet 0.5 mg give 1 tablet by mouth every 8 hours as needed for anxiety. The aforementioned Physician's order for Alprazolam had no end date for the medication to be reevaluated. 6/16/23 at 1:50 PM - An interview with E3 (ADON) confirmed that the order for the PRN Alprazolam should have been renewed every 14 days and there was no Physician documentation to extend the original order. 6/16/23 at 2:30 PM - A Physician's order was renewed for Alprazolam tablet 0.5 mg give 1 tablet by mouth every 8 hours as needed for anxiety. The facility failed to provide evidence that R9 was reassessed by the Physician for the need to extend the use of Alprazolam for more than 14 days. 6/21/23 12:20 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E4 (ED) at the exit conference.

Based on clinical record review, interview and review of facility documentation as indicated, it was determined that for one (R9) out of two sampled residents reviewed for accidents, the facility failed to ensure the resident's environment remained as free of accident hazards as was possible. For R9, an unsafe transfer was performed using a Sit-to-Stand mechanical lift with only one CNA as opposed to a Hoyer Lift (full body mechanical lift) with two CNA's per R9's plan of care, resulting in a fracture of R9's left leg. The unsafe transfer caused R9 harm. Based on review of the facility's evidence to correct the non-compliance and the facility's substantial compliance at the time of the current survey for F689, the specific regulatory requirement, the deficiency was determined to be past non-compliance. Findings include: A facility policy entitled Lift/Transferring/Repositioning Resident Safely (last revised 12/2018), included: a. Adhere to the designated lifting / transferring / repositioning technique per assignment. b. CNA's may always choose to use more help than assigned, but never less. c. Report any unsafe acts . d. Two employees will always be available when using a lift for residents who have no weight bearing ability and cannot provide assistance or balance. The following was reviewed in R9's clinical record: 5/8/15 - R9 was admitted to the facility with dementia. 12/27/18 - Review of the physical therapy plan of care documentation recommended that since R9 remained dependent and was an assist of two facility staff for transfers, the physician's order must remain that R9 continue to be transferred by a Hoyer lift and for the resident's care plan intervention to reflect a Hoyer transfer as well. 9/29/19 and 12/29/19 - A quarterly and significant change MDS assessment (respectively prior to the 1/14/20 incident) documented that R9 was cognitively impaired, dependent with the assist of two staff for transfers and had not walked or moved from a seated to a standing position. R9's care plan reflected the MDS documentation to use a mechanical lift for transfers with the assist of two staff. 1/14/20 11:19 PM - A progress note documented Resident (R9) complain(ed) of pain on her left leg. Was medicated with as needed Tylenol. 1/17/20 8:00 AM - A nursing progress note documented c/o (complained of) left knee pain, swelling present, ice applied. 1/17/20 8:06 AM - A nursing progress note included, CNA reported to this nurse change of condition in resident. Swelling to left knee measuring 49 cm and right knee measuring 43 cm (centimeters) .waiting to notify provider for further assessment. 1/19/20 9:43 AM - A nursing progress note documented Bilateral (both) knees are swollen. Resident denies any pain or discomfort at present time. She is oob (out of bed) to wheelchair. For last 2 days her left leg has been 'floppy' below her left knee. NP (Nurse Practitioner) saw resident on Friday [1/17/20] and ordered ice. Will continue to monitor. 1/20/20 9:53 AM - A nursing progress note documented For the last 3 days her left leg has been floppy. E11 (MD) in to see her this morning. 1/20/20 10:19 AM - A nursing progress note documented [X-ray company] in to do x-ray to the left knee. 1/20/20 4:22 PM - A nursing progress note included, E11 (MD) called and made aware of the left knee XR (x-ray) and ordered for the resident to be sent to the ER (emergency room ) for evaluation. 1/20/20 7:47 PM- A nursing progress note documented Received a call from ER (name of Emergency Nurse - SS1), resident will be sent back with DX (diagnosis of) left knee fracture. The facility's investigation report and supporting documents revealed the following: -1/21/20 11:33 AM - A complaint report to the State Agency included, The resident started on Thursday 1/16/20 with some swelling to knee. No pain or discoloration. The nurse practitioner examined on Friday 1/17/20 and ordered ice. Swelling increased over the weekend and the physician ordered an x-ray and lab work . X-ray shows .left knee fracture. - 1/21/20 (untimed) - E15's (CNA) initial statement stated, On Monday Jan (January) 13, I worked half of day for E31 (CNA) 11 AM - 3 PM. Noticed nothing on (R9). I worked Tuesday (1/14/21) 7 AM - 3 PM. I gave (R9) a shower. I did not work Jan. 15 or 16 th. I was back on the 17th of Jan., but we worked with six, so I didn't have her (R9) in my group. - 1/22/20 (untimed) - E16's (CNA) Statement stated, On Tuesday (1/14/21) we heard a call over the 'walkie' that someone needed help in the shower room. It was E15 (CNA). She had R9 on the sit to stand (lift) and R9 was coming down (about to fall), so (E15) asked me to help her get her (R9) in the chair. So I grabbed R9 by the seat of her pants and we pulled her back in her chair. E15 was saying at least she did not fall. - 1/23/20 - E15's (CNA) second statement (after E16's statement) stated, On Jan (January) 14, 2020 R9 was not in my group, but the aide on the end E18 (CNA) was struggling so I gave her a shower for her. I did Hoyer (a mechanical lift) her into shower chair and proceeded into shower to give her a shower. R9 had a large loose BM (bowel movement) so I was trying to clean her up. I couldn't get her bottom good, so I did use the sit to stand lift to clean her bottom well. While on the sit to stand, resident's foot slipped. I was holding on to her. I did not let her fall. I used my walkie-talkie to call for help. E16 (CNA) came and we got her back in her chair. I asked R9 if she had pain. She said no. I did not report this to the nurse because she did not fall or hit the floor. After the facility became aware of the witness statement (written by E16) and gained knowledge of the improper/unsafe transfer (using the wrong lift and being alone), E15 was immediately suspended pending the incident investigation. 1/28/20 - E15 was terminated from the facility based on results of the investigation for serious misconduct and neglect of a resident's safety. 11/3/21 10:35 AM - During an observation and interview of R9's transfer to her wheelchair, 2 CNA's completed the correct transfer for R9 and reported that they found the transfer status of all residents in the CNA documentation. 11/4/21 at approximately 2:30 PM - During an interview with E1 (NHA), findings were reviewed. The facility confirmed that an unsafe transfer with the improper lift was performed by E15 (CNA) resulting in a left leg fracture above the knee. E1 showed that the facility conducted a thorough investigation, identified the failure, and immediately initiated a Performance Improvement Plan with multiple interventions as evidenced by the facility referenced sign-in sheets, including the following: 1. A review of all resident transfer status' with therapy and nursing was completed by 1/30/20. 2. Education was provided and content was signed off by employees to ensure patient safety during mechanical lift transfers was completed by 1/30/20, as dated on the inservice sheets. 3. All resident's transfer status' were reviewed to ensure they were correct and available in the computer for nursing, including CNA documentation by 1/30/21. Based on review of the aforementioned facility corrective actions, it was determined that the facility regained substantial compliance with F689 on 1/30/20. Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference on 11/5/21, beginning at 12:00 PM.

Based on observation and interview, it was determined that the facility failed to ensure safe and sanitary storage of food in one out of two unit nourishment refrigerators. Findings include: During numerous tours of the two nutrition rooms throughout the day on 11/1/21, the surveyor observed the following: 11/1/21 10:26 AM - The unit refrigerator in the nutrition room on the Lewes Short hall had five (5) undated, unlabeled black plastic food containers and a white plastic bag containing two (2) additional undated, unlabeled black plastic food containers identified by E7 (Nutritional Service Manager) as food brought in by family members for a specific resident. The top shelf of the refrigerator had a large unsanitary area covered with a light purple, sticky substance. Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference on 11/5/21, beginning at 12:00 PM.

Based on record review and interview it was determined that, for six (R2, R3, R11, R22, R25 and R31) out of six residents investigated for unnecessary medication review, the facility failed to ensure records were accurate and complete. Findings include: 1. 11/2/21 at approximately 12:40 PM - During an interview with E1 (NHA), the Surveyor requested copies of the monthly pharmacy review reports for the previous twelve months for the five residents (R2, R3, R11, R22 and R25) selected for unnecessary medication review. 11/3/21 at approximately 10:30 AM - During an interview, E2 (DON) informed the Surveyors that they (the facility) were trying to locate all of the information requested for drug reviews since they were not in one location. 11/4/21 at 9:30 AM - E11 (MD) confirmed in an interview that he responded within 30 days of receiving the pharmacy recommendations, but was not sure why the facility could not locate the records (paper copies) of his response. 11/3/21 at 3:43 PM - E1 (NHA) provided copies of the pharmacy drug review reports and stated that documents had not been scanned into the clinical records for the past three months since the staff member who used to do the scanning was reassigned to do scheduling. 11/4/21 at 10:23 AM - During an interview, E1 stated that, as of yesterday, the pharmacy reports were now being keep in a binder until they get scanned into the records. 2. Review of R31's clinical record revealed: 10/10/21 - Physicians' Orders included blood tests for the next day. 11/2/21- There were no laboratory results in the scanned records nor the paper chart. 11/2/21 at approximately 10:05 AM - During an interview, after the Surveyor asked E14 (RN) where the lab results would be located, E14 stated they would be in the scanned into the record. E14 confirmed the blood test results were not in the electronic record and left the room. Within a few minutes, E14 presented a paper copy of the results to the Surveyor and stated they had to be printed. Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference on 11/5/21, beginning at 12:00 PM.

Based on observation, interview, and record review it was determined that the facility failed to provide appropriate infection surveillance for one resident (R11) out of two residents reviewed for constipation and diarrhea. The facility failed to isolate R11 when the resident continued to have symptoms of [CONDITION(S)] Infection (infectious loose stools). Additionally, the facility failed to follow the core principles of COVID-19 infection prevention for staff use of PPE (personal protective equipment) in the kitchen area. Findings include: According to the Centers for Disease Control (https://www.cdc.gov/cdiff/clinicians/faq.html): Isolation for C-Diff should continue until loose stools cease. The organism that causes the loose stools continues to be present in the stool even though antibiotics have been completed. According to the CDC, source control referred to well-fitting masks to cover the person's mouth and nose to prevent the spread of respiratory secretions when they breathe, talk, sneeze or cough. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html (Accessed 11/2/21) 1. 7/14/21 - R11 was admitted to the facility. 9/22/21 - The Resident was placed on isolation precautions for [CONDITION(S)] Infection (CDI) and started an antibiotic by mouth. 10/6/2021 10:59 AM - R11 received the last dose of the antibiotic, completing the CDI treatment. 10/6/21 1:04 PM - A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 10/7/21 - A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 10/8/21 12:57 PM - A progress note revealed the lab called to inform staff that R11's stool sample was formed and could not be tested for CDI. The note stated the Physician was made aware of this. 10/8/21 - 10/28/21 - CNA documentation revealed R11 was having 2-3 loose stools daily. 10/28/21 - A Doctor's Order written by E11 (MD) revealed that another stool sample was ordered for CDI. 10/31/21 7:22 AM - A progress note revealed that another stool sample was obtained for CDI testing. 11/1/21 1:42 PM - During an interview, R11 stated that he had been having stools that were black and loose. 11/2/21 - Record review did not reveal any results from the stool sample sent for testing on 10/31/21. 11/2/21 - Record review showed no evidence that isolation precautions were ordered when R11 was having loose stools and waiting for CDI sample results. 11/2/21 2:00 PM - An observation confirmed that R11's room was not set up for isolation precautions. 11/3/21 3:55 PM - In an interview, E20 (NP) stated that R11's stool sample was run as another kind of test in error so CDI results were not obtained. E20 stated she was ordering another stool sample for CDI since R11 was still having watery stools daily and was not on any stool softeners. 11/3/21 4:00 PM - A progress note written by E20 revealed she had spoken with E11 (MD) about R11's stool results. E20 obtained records from the lab that a stool specimen was collected on 10/31/21, but the lab ran the incorrect test on it. 11/3/21 5:00 PM - E20 ordered another stool sample be collected to test for CDI. 11/3/21 - A record review of CNA documentation revealed three incontinent stools in a 24 hour period and two were loose. 11/4/21 2:40 AM - A progress note revealed that a stool sample was collected for CDI. The note also stated that R11 was placed on isolation precautions. 11/4/22 4:22 AM - R11's record documented a large loose incontinent bowel movement. 11/5/21 3:44 AM - A nursing progress note revealed that R11's stool sample was positive for CDI and the Physician ordered an antibiotic. 11/5/21 10 :00 AM - A review of R11's record revealed that he was not in isolation for 29 days without a negative CDI sample. 2. 11/1/21 - During the initial and follow-up kitchen observations throughout the day, numerous staff were seen wearing their facemasks inappropriately, with either their nose and/or mouth exposed: - 9:19 AM - E22 (Cook) was preparing food with no facemask leaving her nose and mouth exposed. - 9:22 AM - E25 (Cook) was preparing food during the initial kitchen tour and three (3) follow-up kitchen tours with his facemask pulled down below his chin, leaving his nose and mouth exposed. - 9:49 AM- E23 (Cook) was observed with his facemask pulled down below his chin, leaving his nose and mouth exposed. - 10:08 AM - During an interview, E22 (Cook) stated, I don't wear a mask because I stay in my area and I am fully vaccinated. - 10:09 AM - E35 (Kitchen Staff) was observed with her facemask pulled down below her chin leaving her nose and mouth exposed. - 10:17 AM - E24 (Cook) was observed with his facemask pulled down below his chin, leaving his nose and mouth exposed. 11/1/21 11:46 AM - During an interview, E7 (Nutrition Services Manager) stated, The mask wearing policy is from gate to gate for all employees, which means you wear your mask all day unless you are eating. 11/1/21 12:27 PM - During an interview, E21 (Dining Manager) stated, I believe vaccinated non-direct care staff are requested to wear masks, but it is not required. Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate DON) during the exit conference, beginning at 12:00 PM.

Based on observation and interview it was determined that the facility failed to provide meal service in a dignified manner for 18 randomly observed residents in the Magnolia Dining Room, as evidenced by serving staff wearing disposable gloves to serve resident meals. Findings include: 11/1/21 12:12 PM - During a random lunch observation in the Magnolia Dining Room, serving staff were seen wearing gloves while serving residents their lunch meals. 11/2/21 12:31 PM - A random observation of 18 residents during lunch in the Magnolia Dining Room revealed the servers were wearing vinyl gloves while serving residents. An interview immediately following the observation with E8 (server) stated the facility policy included wearing gloves to serve and changing gloves between tables and hand hygiene with glove changes. 11/3/21 8:21 AM - A random observation of 12 residents during the breakfast meal in the Magnolia Dining Room revealed that serving staff were wearing gloves while serving breakfast to the residents. 11/3/21 12:45 PM - A review of the corporate policy for meal service (ACTS M-02.1), updated 5/2000, did not include wearing gloves for resident meal service as E8 suggested. 11/3/21 2:44 PM - During an interview with E7 (Nutrition Services Manger), she stated that she thought the servers were supposed to be wearing gloves to serve meals. Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference on 11/5/21, beginning at 12:00 PM.

Based on observation, interview and review of facility policies and procedures it was determined that the facility failed to ensure the policy and postings included the process to file a grievance anonymously and/or identifying the Grievance Official. Findings include: Review of a facility policy entitled Grievance Report (revised October 2017) revealed that, although the policy contained a statement that A grievance may be filed anonymously, the process for how to file a grievance anonymously was not described. 11/5/21 at 10:15 AM - During an observational interview, E1 (NHA) confirmed that the posting entitled Filing a Grievance Report, did not include the Grievance Officials name and contact information or how to file a grievance anonymously. The postings were available for resident and responsible party/family viewing. Findings were reviewed with E1 and E2 (DON) during the exit conference on 11/5/21, beginning at 12:00 PM.

Based on record review and interview it was determined that, for two (R15 and R28) out of thirteen (13) active residents sampled for an investigation of a care area, the facility failed to ensure the Admission MDS assessments were accurate. Findings include: 1. Review of R15's clinical record revealed: 8/27/21 - R15 was admitted to the facility under [name of Hospice] services. Hospice is a service that provides care to terminally ill residents. The Admission MDS assessment incorrectly documented R15's prognosis. The question Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months was answered No. 11/4/21 at 12:38 PM - During an interview with E1 (NHA) and E2 (DON), the Surveyor reviewed the MDS error and E1 stated she would look into it since the MDS Nurse worked the evening before. 2. Review of R28's clinical record revealed: 9/29/21 - R28 was admitted to the facility after having a stroke. 10/5/21 - The Admission MDS assessment documented that R28 received six doses of an anticoagulant (blood thinner) during the seven day look-back period. September - October 2021 - Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 11/4/21 at 12:38 PM - During an interview with E1 (NHA) and E2 (DON), the Surveyor reviewed the MDS error and E1 stated she would look into it. 11/5/21 at 11:30 AM - The facility provided no additional information. Findings were reviewed with E1 and E2 during the exit conference on 11/5/21, beginning at 12:00 PM. During the exit conference, E2 stated the MDS assessments had been modified and the errors were fixed.

Based on record review and interview it was determined that, for one (R15) out of thirteen (13) active residents investigated for a care area, the facility failed to ensure that the required interdisciplinary team members including the Physician and Nurse's Aide, attended or provided input for development of the comprehensive person-centered care plan. Findings include: Review of R15's clinical record revealed: 8/27/21 - R15 was admitted to the facility. 9/9/21 1:33 PM - A Care Conference Note documented that the spouse and two sons were invited and did join via telephone, [name of Hospice] spoke with the family and staff prior to care plan . She is on hospice due to her current diagnosis. 11/4/21 at 9:28 AM - During an interview, E14 (RN) stated that she asked the aides before the meeting. After the Surveyor commented that the regulation included those attending or providing input to the care plan, E14 said that she should document that they (CNA's) provided information. 11/4/21 at 10:02 AM - During an interview with E9 (SW), the Surveyor asked who attended the care conference since the Care Conference Note did not identify who attended or provided input to the development of the care plan. E9 stated that, besides herself, E10 (Activities) and a Nurse. E9 added that someone from Dietary would call in as needed. When asked if the Physician or CNA attended, E9 indicated that the CNA might be called in to the meeting, but the physician did not attend the care conferences. Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference on 11/5/21, beginning at 12:00 PM.

Based on observation, interview, and record review it was determined that, for two (R3 and R28) out of thirteen (13) active residents sampled for an investigation of a care area, the facility failed to follow physician orders. Findings include: 1A. Review of R3's clinical record revealed: 4/21/21 - R3 was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 4/22/21 - A review of R3's care plan revealed the resident had an intervention for no straws. 4/22/21 - A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 5/1/21 - Review of R3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 10/27/21 - A review of R3's quarterly MDS assessment revealed choking when drinking liquids. 11/1/21 11:20 AM - An observation revealed that R3 had a water cup in her room without a straw. R3 stated she needs a straw to drink, but someone had taken it out to use it for something else. 11/2/21 9:00 AM - A random observation revealed that there was a straw in R3's water cup in the resident's room. 11/2/21 9:15 AM - An interview with E5 (RN) confirmed that the resident was not supposed to have straws in her drinks because of swallowing precautions and stated she would remove it. 1B. A review of R3's clinical record revealed: Cross refer F756 9/9/21 - E11 (MD) ordered a blood test for uric acid. 11/3/21 - A review of lab orders and blood test results revealed no evidence that uric acid levels were obtained over the previous six months. 11/3/21 4:00 PM - A review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 11/4/21 9:30 AM - E11 confirmed in an interview that the facility called him on 11/3/21 to obtain orders for magnesium (which had previously been recommended by the pharmacist) and uric acid levels. 11/4/21 10:47 AM - Lab results revealed that R3's uric acid level was 3.1 (normal range 2.6 - 6.0) and magnesium level was 3.0 (normal range 1.6-2.6). 11/4/21 - E11 (MD) discontinued the magnesium supplement. 2. Review of R28's clinical record revealed: 9/29/21 - R28 was admitted to the facility after having a stroke. 9/30/21 - The Physicians' Orders included Milk of Magnesia (MOM - a [MEDICATION(S)]) to be given for constipation if no bowel movement (BM) for three days. September - November 2021 - Review of CNA documentation and the eMAR revealed: - October 16: medium BM on day shift. - October 17, 18, 19: no BM. - October 20: MOM not administered after three days without a BM. - October 21: MOM administered at 8:19 PM. The Physicians' Order was not followed since R28 did not receive MOM until she had gone four days without a BM. 11/4/21 at 12:38 PM - During an interview with E1 (NHA) and E2 (DON), the Surveyor reviewed the BM information and asked if BMs could have been written elsewhere, like on a bowel protocol sheet. 11/5/21 at 11:30 AM - No additional BM information for R28 was provided by the facility. Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference on 11/5/21, beginning at 12:00 PM.

Based on record review, observation and interview it was determined that, for one (R15) out of one resident investigated for position/mobility, the facility failed to implement care and services to prevent a further reduction of range of motion. Findings include: Review of R15's clinical record revealed: 8/27/21 - R15 was admitted to the facility with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 10/5/21 - Review of Range of Motion (ROM) measurements completed by Therapy revealed that R15 had moderate impairment (contracture) of her left elbow, left wrist, left fingers, left hip, left knee and both ankles. Recommendations included Passive ROM (extent to which a joint can be moved or straightened safely with/by staff) to upper and lower extremities for 15 minutes twice a day. 10/30/21 - A care plan was developed for having visible changes in joint mobility [contractures] with the intervention to perform PROM to arms and legs on both sides for 15 minutes twice a day. October 2021 - Review of CNA documentation revealed the task to perform PROM was not added until 10/30/21, 25 days after the Therapy recommendation. 11/3/21 at 4:15 PM - An interview with E17 (Hospice Case Manager) revealed that R15 was still on Hospice Services and that Therapy (Physical, Occupational or Speech Therapy) was not covered and that ROM would need to be completed by nursing staff. 11/4/21 at approximately 8:54 AM - During an interview, when asked if R15 had done ROM, E13 (CNA) said that R15 Just came off of hospice and added that It hurts her when I open her hand. Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference on 11/5/21, beginning at 12:00 PM.

Based on observation, interview and review of facility policy and procedure, it was determined that for two (R25 and R337) out of two residents reviewed for respiratory care, the facility failed to provide respiratory care consistent with professional standards of practice. Findings include: A facility policy entitled Use and Care of Equipment (last revised 11/20) included, Nasal cannulas .which are used to deliver oxygen .should be dated when changed. 1. 11/1/21 1:39 PM - During an observation and interview it was noted that R337's oxygen tubing did not have a date on it. This was confirmed by E29 (LPN). 2. 11/2/21 12:26 PM - During an observation and interview it was noted that R25's oxygen tubing on a portable oxygen tank did not have a date on it. This was confirmed by E5 (RN). E5 stated that they usually date the tubing when it is changed. Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference on 11/5/21, beginning at 12:00 PM.

Based on record review and interview it was determined that, for two (R2 and R3) out of five residents reviewed for unnecessary medications, the facility failed to ensure that irregularities identified by the pharmacist were reviewed by the physician in a timely manner and/or include a response. Additionally, the facility's drug review policy did not include the time frame for the pharmacist to provide the facility with results of the drug reviews. Findings include: 1. Review of the facility policy entitled Pharmacy Services (dated 7/2018) stated, The licensed pharmacist will conduct a monthly medication regime review . Irregularities noted by the pharmacist during the review will be documented on a separate, written report . The report will be reported to the attending physician, community's medical director and the director of nursing. These reports must be acted upon monthly or within the states (sic) physician visit guidelines. Any irregularities that require urgent action will be promptly reported to the attending physician and director of nursing by fax, email or phone by the consultant pharmacist. The attending physician must document in the resident's record that the identified irregularity has been reviewed, and what, if any action has been taken to address it. If there is to be no change in the medication, the attending physician should document the rationale in the health record. The policy did not specify the time frame for the pharmacist to report non-urgent irregularities to the facility. 2. Review of R2's clinical record revealed: 3/8/21 - The Pharmacist recommended to increase the dose of [NAME] (blood thinner). The Pharmacy Consultation Report was signed by E11 (MD) on 9/20/21, six months after the irregularity was identified. E11 did not indicate a response. 5/9/21 - The Pharmacist recommended to start a Vitamin D supplement twice a day. E11 signed the report on 9/20/21, four months after the pharmacy review. E11 did not indicate a response. 3. Review of R3's clinical record revealed: 4/21/21 - R3 was admitted to the facility after a stroke. 4/22/21 - Physicians' Orders included [MEDICATION(S)] for the treatment of gout (joint pain, especially in the feet) and Magnesium as a supplement. 6/6/21 - A Pharmacy Consultation Report suggested that R3 have two blood tests (magnesium and uric acid) on the next blood test day and repeat every six months since R3 was receiving Magnesium and [MEDICATION(S)]. There was no evidence in R3's record that these tests were acknowledged by the physician. July 2021 - August 2021 - No Pharmacist recommendations were made although the June 2021 recommendations were not reviewed. 9/3/21 - The Pharmacist recommended for the second time, that a uric acid level be obtained. E11 (MD) signed and accepted the recommendation on 9/9/21, approximately three months after it was first recommended by the Pharmacist. 11/3/21 4:00 PM - A review of physician orders revealed that E12 (RN) received a telephone order from E11 (MD) for magnesium and uric acid levels to be drawn on 11/4/21 and then repeated every six months; approximately five months after it was first recommended by the Pharmacist. Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference on 11/5/21, beginning at 12:00 PM.

Based on clinical record review, review of other documentation, and interview it was determined that the facility failed to follow the plan of care and failed to provide care and services to one (R7) out of 9 residents sampled. R7 was left unattended, not positioned in the proper chair and without alarms to alert staff resulting in an unwitnessed fall and subsequently a [MEDICAL CONDITION]. After the fall the staff stood R7 up and transferred her to a wheelchair then to a recliner. After R7 was assessed for a possible fracture and expressed pain R7 was incorrectly transferred using a sit to stand lift twice. The staff did not follow the policy and procedure for transferring R7 after the fall. The staff also failed to do neurochecks for R7 who had an unwitnessed fall. Findings include: The Falls Reduction and Management policy and procedure stated "ensure that the proper designed chair is used for the resident's specific problems." R7 was admitted to the facility with [DIAGNOSES REDACTED]. R7's Minimum (MDS) data set [DATE] stated that she had moderately impaired vision, had both long and short term memory problems, and she rarely understood others. R7 was also assessed for being moderately impaired for decision making and she required extensive assistance with one person to assist with transfers. Review of R7's Fall Assessment Form revealed on 10/26/10 that R7 was assessed to have a score of "7" which indicated she was a "high risk" for falls. Review of R7's care plan revealed she was care planned for being :"at risk for falls r/t dementia and unsteady gait" with interventions that included "8. Personal alarm at all times". The CNA care plans stated she had special considerations that included "personal alarm and when out of bed patient must be in recliner chair." Review of R7"s ADL plan of care revealed "cautions balance problems high risk for falls". Review of R7's nurses notes dated 2/16/11 at 10:20 AM documented "Writer alerted to lobby/TV area at Rehoboth nurse station, alerted by E3 (adon/rnac) Patient found lying face up in front of the TV alert and verbal, resident able to stand, full range of motion to arms however with assessment of legs patient showed facial grimacing with movement of right leg, charge nurse alerted." Review of R7's clinical record revealed there was no documentation indicating that neurological assessments were started for R7 after her unwitnessed fall. R7 was admitted to hospital with a right femoral neck fracture. Review of the facility's incident report revealed on 2/16/11 "Resident found by E3 (adon/rnac) lying on the floor face up, alert, verbal (short yes/no answers). Resident lying face up in front of TV/Lounge/Rehoboth wing, upon range of motion assessment full range of motion to bilateral arms and left leg; however patient had facial grimacing and guarding with range of motion of right leg/hip. Received orders to send patient for evaluation at (hospital)..." Review of a written statement by E6 (CNA) that described the events prior to the fall revealed she put R7 in a wheelchair because she could not find R7's chair. E6 stated she forgot to put R7's alarm on her and left R7 in a wheelchair instead of a recliner without the alarm, unattended and went on break. While on break R7 stood up from the wheelchair walked around and fell . The facility's policy and procedure for "Preferred Methods for Lifting and Transferring" residents stated "Lifts from Floor. A resident who has fallen to the floor will be assessed for injury prior to being lifted. In situations where a resident must be lifted from the floor by associates; a full sling mechanical lift will be required." Extensive Assistance Residents- All residents classified as extensive assistance should be lifted and transferred between beds, chairs...with the aid of a mechanical lift device. A full body sling lift, ... is appropriate for all transfers. ....depending upon the resident's cognitive status and /or weight bearing capabilities a stand assist lift ... may be used..." Review of the video tape of the fall with E7 (director of physical plant) on 6/1/11 at 12:45 PM revealed that E6 (CNA) went on break at 9:41 AM. At 9:43 AM R7 got up out of the wheelchair walked around then fell . E3 (adon/rnac) was observed walking down the hall. E3 continued to walk around the corner, left her cart and continued down the hallway. E3 returned to the TV room, looked down at R7 then left, and went down the hallway again leaving R7 on the floor unattended. E3 returned and was observed getting down on the floor with R7. E6 (CNA) was observed bringing a hoyer lift to the area where R7 was lying on the floor. At 9:53 AM E3 (adon/rnac), E10 (nurse), and E11(nurse) were observed standing R7 up and transferring her to a wheelchair then they transferred R7 to a recliner without using the lift. At 10:28 AM E6 and E8 (two CNAs) were observed using the sit to stand lift to transfer R7 from the recliner to a wheelchair. The video showed E6 leaving the TV area with R7 in a wheelchair. Interview with E8 (CNA) on 6/1/11 at 1:15 PM revealed she was told by the nurse to use the sit to stand lift to put R7 in bed. E8 stated she assisted E6 in using the sit to stand lift to transfer R7 from the wheelchair to the bed. Review of the incident with E4 (RN supervisor) on 6/1/11 at 1:55 PM revealed E6 (CNA) was terminated for leaving R7 unattended, in the wheelchair instead of a recliner, without the alarms and going on break. E4 continued to state that the E3 (adon/rnac) should not have left R7 unattended when she saw her on the floor. E3 should have yelled for help and stayed with R7. E4 confirmed that once the nurses identified that R7 had pain with movement of her leg and hip the staff should not have transferred her. E4 also confirmed that no neurological checks were done for R7 and should have been done because it was an unwitnessed fall with her head on the floor. E4 also stated that the 3 nurses involved (E3, E10, and E11) were given a written discipline. However, at the conclusion of the facility investigation no formal education or training had been done with the staff on how to assess, how to transfer a resident after a fall or what actions to take when a resident falls. E4 continued to state that the facility did not have a policy and procedure or protocol in place addressing post fall assessments. On 6/2/11 at 9:45 AM interview with E3 (adon/rnac) revealed that when R7 was on the floor her foot was slightly turned and they did range of motion with her and then stood her up. E3 continued to state that they did not know R7 had pain until we reassessed her leg when she was in the recliner. R7 grimaced when the range of motion was done when she was in the recliner. E3 stated no formal education was provided to the staff on resident falls and their was no policy and procedure for post fall assessments. She continued to say that she left the R7 unattended to get help. E3 also stated that neurological assessments are not done on a resident unless the staff are sure the resident hit their head, even if it was a unwitnessed fall. On 6/2/11 at 12:25 PM interview with E9 (Physical Therapist) revealed that when a resident is found on the floor the staff are to use a full sling lift to lift them off the floor. E9 continued to state that a sit to stand lift should not be used on a post fall resident especially when a fracture is suspected.