cms_DE
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| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity ▼ | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 166 | 166 | REGAL HEIGHTS HEALTHCARE & REHAB CENTER | 85006 | 6525 LANCASTER PIKE | HOCKESSIN | DE | 19707 | 2019-11-07 | 550 | B | 0 | 1 | T39711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, it was determined that the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each residents' dignity and respect in full recognition of his or her individuality by multiple observations of residents not being provided glasses to drink from instead of milk cartons and prefilled plastic juice containers. Additionally, observations were made of residents drinking from disposable plastic cups. An interview revealed that facility staff failed to honor A1's (anonymous resident) request for privacy while using the bathroom. Findings include: 1. 10/29/19 12:55 PM - During the dining observation in the Eastburn unit, E6 (CNA) opened R81's [MEDICATION NAME] milk carton, but did not pour the milk into a drinking cup or glass. 10/29/19 1:17 PM - An interview with E6 (CNA) revealed that a non disposable drinking cup or glass was not provided on the tray from the Dietary Department for R81's milk to be poured into. 2. 10/29/19 1:20 PM - During the dining observation in the Eastburn unit, R39's milk carton was opened by E7 (CNA), but was not poured into a drinking cup or glass. R39 was observed spilling milk on his shirt while trying to drink from the carton. Findings were reviewed with E1 (NHA) and E2 (DON) during the Exit Conference on 11/7/19 at 6:15 PM. 3. Observation on 10/29/19 from 12:43 PM through 1:10 PM revealed R145 drinking juice and water from disposable plastic cups during the midday meal. Although the water arrived on the tray in a reusable plastic cup, a staff member poured half of it into a disposable plastic cup. 4. Observation on 10/29/19 from 12:43 PM through 1:10 PM revealed R82 drinking juice from a disposable plastic cup during the midday meal. 5. Observation on 10/29/19 from 12:43 PM through 1:10 PM revealed R68 drinking milk from a disposable plastic cup during the midday meal. 6. Observation on 10/29/19 from 12:43 PM through 1:10 PM reve… | 2020-09-01 |
| 182 | 182 | REGAL HEIGHTS HEALTHCARE & REHAB CENTER | 85006 | 6525 LANCASTER PIKE | HOCKESSIN | DE | 19707 | 2019-11-07 | 842 | B | 0 | 1 | T39711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview, it was determined that for two (R58 and R123) out of 67 residents sampled, the facility failed to ensure that the residents' clinical records were accurately documented. Findings include: 1. Review of R58's clinical record revealed: 8/11/19 - R58 was sent to the emergency room . She was diagnosed with [REDACTED]. 8/14/19 at 8:08 AM - A physician's note stated, .8/14/19 . readmission note/hospital record review . s/p (status [REDACTED]. presented to hospital after choking episode while eating . was admitted for Aspiration pneumonitis . was seen by speech therapy during this hospitalization and started her on a dysphagia 1 diet . She had a fall on 8/11/2019 with no injury. The recent fall or injury likely exacerbated by the UTI . 8/18/19 at 1:55 PM - R58 experienced a choking incident during lunch and was sent to the hospital for evaluation and admitted . 8/25/19 - R58 was discharged from the hospital with a [DIAGNOSES REDACTED]. The facility failed to ensure that R58's medical record was accurately documented when a physician's note/H&P, dated 8/14/19, documented a choking incident that occurred on 8/18/19. 2. Review of R123's clinical record revealed: 9/23/19- A quarterly MDS assessment stated that R123 required 2+ staff person assist for bathing. R123's ADL care plan, last revised on 5/26/16 and last reviewed on 9/23/19, indicated that R123 was to be a two staff person extensive assist for bathing. Review of the CNA documentation report for bathing revealed that R123 was documented as one staff assist instead of 2+ staff assist for bathing on 10/15/19, 10/25/19, 10/20/19, and 11/3/19. The facility failed to accurately document R123's clinical record with respect to staff assistance for bathing. Findings were reviewed and confirmed by E1 (NHA) and E2 (DON) on 11/6/19 at approximately 10 AM. | 2020-09-01 |
| 241 | 241 | MILFORD CENTER | 85010 | 700 MARVEL ROAD | MILFORD | DE | 19963 | 2018-06-15 | 584 | B | 0 | 1 | TG4C11 | Based on observation and interview it was determined that the facility failed to ensure the interior was maintained in a sanitary, orderly and comfortable manner. The upholstered furniture on one (Homestead unit) out of 3 nursing units was dirty and stained and lacked a routine cleaning schedule. Findings include: 1. 6/4/18 - 6/8/18 - Observation of dining chairs, lounge chairs/sofas on the Homestead (Memory Support) unit revealed dirty and stained seating in the lounge, activity/dining rooms and area by nursing station. 29 out of 30 seating pieces of upholstered furniture were stained and/or had dirty arm rests (21 out of 22 armed dining chairs, 4 out of 4 sofas, 5 out of 5 lounge chairs, 5 out of 5 upright chairs in front of television). One sofa had even been turned around facing backwards to prevent use on 6/5/18 - 6/8/18, due to an incontinence episode by a resident. During an interview with E61 (Housekeeper) on 6/8/18 at 11:40 AM, confirmed that the furniture was stained and dirty and did not get regular cleaning since the unit had to wait for them (staff who usually clean the floors) to get time to clean the furniture. | 2020-09-01 |
| 297 | 297 | MILFORD CENTER | 85010 | 700 MARVEL ROAD | MILFORD | DE | 19963 | 2017-07-13 | 253 | B | 0 | 1 | 9SIB11 | Based on surveyor observations and a resident interview, it was determined that the facility failed to ensure resident rooms were in good repair and that a privacy curtain was clean. This deficient practice was evident for 4 of 33 rooms observed during Stage 1 and Stage II. Findings include: Surveyor observations and interview revealed: On 7/5/17 at 2:08 PM Room 220 - privacy curtain stained and there was wheelchair damage in bathroom and walls 7/5/17 at 3:55 PM Room 112 - wheelchair damage to walls in bedroom 7/7/17 at 11:21 AM Room 221- walls are scarred, in room and bathroom 7/7/17 at 1:04 PM Room 118 - areas of room, bathroom door jam, and the bathroom door were damaged 7/13/17 between 9:35 AM and 9:43 AM, a surveyor observed that the above findings were still present. The surveyor interviewed a resident who chooses to be anonymous that stated he/she is not aware of staff ever taking a privacy curtain down to clean. The surveyor discussed the above findings with E1 (NHA) and E2 (DON) at the exit conference on 7/13/17 at approximately 2:15 PM. | 2020-09-01 |
| 436 | 436 | SEAFORD CENTER | 85015 | 1100 NORMAN ESKRIDGE HIGHWAY | SEAFORD | DE | 19973 | 2019-10-29 | 803 | B | 1 | 0 | JVDM11 | > Based on interview and review of other facility documentation it was determined that the facility failed to inform residents of menu changes. Findings include: 6/5/19 - Review of a Grievance / Concern Form revealed the menu around here always changes and no one tells us. E5's (Dietary Manager) response included that the dining department stuff (sic, staff) members must inform Activities Department right away and it would be addressed to all cooks in the dining department. 10/28/19 (8:45 AM - 9:30 AM) - During an interview with the resident council president to request permission to review copies of the past three month's of resident council minutes, the resident council president stated that substitutions to the printed menu frequently occurred without resident notification ahead of time. 10/29/19 (around 9:10 AM) - During an interview E9 (RD) confirmed that a substitution log (document to record the food item was served and the food item it replaced) should be maintained in the kitchen to determine if the item substituted was of a similar nutritional value. 10/29/19 (around 10:30 AM) - During an interview with E5 (Dietary Manager) about staff education in response to grievance/concern form from (MONTH) 2019 regarding menu changes, E5 stated, I did that one but E5 could not provide evidence of all cooks receiving the information. When the surveyor asked to review the substitution log, E5 showed one hanging on the refrigerator door and confirmed there were no logs from prior to (MONTH) 2019. Findings were reviewed with E1 (NHA) and E2 (DON) on 10/29/19 during the exit conference beginning at 2:35 PM. | 2020-09-01 |
| 450 | 450 | COURTLAND MANOR | 85019 | 889 SOUTH LITTLE CREEK ROAD | DOVER | DE | 19901 | 2018-02-27 | 732 | B | 0 | 1 | 6M7M11 | Based on observation and interview it was determined that the facility failed to post required staffing information on two (B and C) of three nursing units. Findings include: B Wing Observation 2/23/18 (10:22 AM) dry erase board at the nursing station with unit census, names of nurse and aides working day shift, the hours each employee was working was not included. C Wing Observation - 2/23/18 (10:50 AM) dry erase board at the nursing station unit census, names of nurse and aides working day shift, the hours each employee was working was not included. - 2/26/18 (10:45 AM) dry erase board included census, names of nurse and aides working day shift, the hours each employee was working was not included. It was also noted that the name of the facility was not included at the top of the dry erase board like on the B Wing. During an interview with E1 (NHA) on 2/26/18 around 1:15 PM it was revealed that the facility does not post facility-wide staffing with the entire census. The information is written on each unit's dry erase board by the nursing station. E1 confirmed that the hours each staff member is working should be included on the board. These findings were reviewed with E1, E2 (DON) and E3 (Assistant Administrator) during exit conference around 1:30 PM on 2/27/18. | 2020-09-01 |
| 486 | 486 | PINNACLE REHABILITATION & HEALTH CENTER | 85020 | 3034 SOUTH DUPONT BLVD | SMYRNA | DE | 19977 | 2018-08-08 | 730 | B | 1 | 0 | 4QXW11 | > Based on interview and review of facility documentation, it was determined that the facility failed to ensure performance appraisals were completed at least every 12 months for 6 (E20, E21, E22, E23, E24 and E25) out of 6 sampled CNAs. Findings include: Review of the latest performance appraisals for 6 randomly selected CNAs revealed the following hire date and (last performance appraisal date): - E20: 3/14/16 (6/15/17) - E21: 4/1/09 (none) - E22: 3/18/09 (7/6/17) - E23: 3/19/12 (2/9/17) - E24: 1/21/14 (6/26/18) - E25: 4/25/11 (6/21/17) E1 (NHA) confirmed the inability to locate any performance appraisals for E21 and that rest of the appraisals were not completed timely. This findings was reviewed with E1 and E2 (DON) during the exit conference on 8/8/18 beginning at 3:15 PM. | 2020-09-01 |
| 671 | 671 | MANORCARE HEALTH SERVICES - WILMINGTON | 85028 | 700 FOULK ROAD | WILMINGTON | DE | 19803 | 2017-08-17 | 253 | B | 0 | 1 | CKVW11 | Based on observations and interviews, it was determined that the facility failed to provide maintenance and house keeping services services for 7 rooms (Dover 232, Heritage 204, 206, 210, Arcadia 113, and New Castle 141, and 143) out of 35 rooms surveyed. Observations made between 8/10/17 and 8/11/17 during the Stage 1 census record review and the Stage 2 environmental tour on 8/15/17 from 3:00 PM to 3:45 PM revealed the following: Dover 232 - There were marks on the wall near the TV; - The wallpaper was pealing off near the floor; - There were marks on the wall next to the window; Heritage 204 - The baseboard along the right side of the wall near the entrance was scraped; - The towel bar in the bathroom was loose; Heritage 206 - The chair rail is scraped; - The wall paper by the mirror was missing; - The long safety rail on the wall in the bathroom was slightly loose; Heritage 210 - The wallpaper along the left side of the wall is in disrepair as you enter room; Arcadia 113 - The caulking around the toilet was in disrepair; New Castle 141 - The towel bar was loose; New Castle 143 - The top of commode lid was improperly closed; - The towel bar was loose; - The wall paper in the bathroom was torn. All findings were reviewed and confirmed with E5 (Maintenance Director) on 8/15/17 at approximately 3:45 PM. | 2020-09-01 |
| 706 | 706 | HARRISON SENIOR LIVING OF GEORGETOWN, LLC | 85029 | 110 W. NORTH STREET | GEORGETOWN | DE | 19947 | 2017-05-11 | 167 | B | 0 | 1 | CR2Z11 | Based on observation and interview it was determined that the facility failed to post notice of the availability of survey results in areas of the facility that were prominent and accessible to the residents on 2 ( two) (Rehabilitation and Sussex Satellite) out of four units and to visitors. Findings include: 5/1/17 (8:25 AM - 9:30 AM) - During the initial tour it was observed that a notice announcing the location of prior survey results was not available for visitors in the lobby nor was posted on the Rehabilitation and Sussex Satellite units accessible to residents. 5/8/17 (3:00 PM) - Tour with E1 (NHA) confirmed the lack of notices indicating the location of prior survey results. These findings were reviewed with E1 and E2 (DON) on 5/11/17 at 2:40 PM. | 2020-09-01 |
| 714 | 714 | HARRISON SENIOR LIVING OF GEORGETOWN, LLC | 85029 | 110 W. NORTH STREET | GEORGETOWN | DE | 19947 | 2017-05-11 | 253 | B | 0 | 1 | CR2Z11 | Based on observation it was determined that the facility failed to provide maintenance services necessary to maintain a sanitary and comfortable interior in 9 (nine) (K2, K22, S19, S27, S32, S36, R1, R2 and R4) out of 36 rooms reviewed. Findings include: Observations were made during Stage 1 (5/1/15 and 5/2/15 8:00 AM - 4:00 PM and 5/3/17 8:00 AM - 12:00 PM) and on environmental tours on 5/8/17 10:00 AM - 10:15 AM and on 5/10/17 11:00 AM - 11:30 AM. K2, S32 and S36 bathroom door kickplates in disrepair K22, S19 and S27 with wall damage R1, R2 and R4 chipped paint on bathroom doorframes These findings were reviewed with E9 (FMD) on 5/11/17 at 10:57 AM and repairs began immediately. These findings were reviewed with E1 (NHA) and E2 (DON) on 5/11/17 at 2:40 PM. | 2020-09-01 |
| 752 | 752 | HARRISON SENIOR LIVING OF GEORGETOWN, LLC | 85029 | 110 W. NORTH STREET | GEORGETOWN | DE | 19947 | 2018-07-18 | 730 | B | 0 | 1 | ZQBV11 | Based on review of facility documentation and interview it was determined that for three (E9, E10, and E11) out of 6 employee evaluations reviewed the facility failed to ensure evaluations were conducted every 12 months. Findings include: 1. E9 was due for an annual evaluation on 4/29/17 and it was not conducted until 4/8/18. 2. E10 was due for an annual evaluation on 8/2/17 and it was not conducted until 3/26/18. 3. E11 was due for an annual evaluation on 10/18/17 and it was not conducted until 3/22/18. An interview with E12 (Human Resources/HR) on 7/18/18 around 12:00 PM revealed that she was hired in (MONTH) (YEAR) after a couple turnovers of HR staff. It was discovered that the facility was behind in staff evaluations. At that time efforts were made to catch up on the evaluations. Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) during the exit conference beginning at approximately 4:15 PM. | 2020-09-01 |
| 1031 | 1031 | ATLANTIC SHORES REHABILITATION & HEALTH CENTER | 85037 | 231 SOUTH WASHINGTON STREET | MILLSBORO | DE | 19966 | 2018-09-28 | 584 | B | 0 | 1 | JOPU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined that the facility failed to provide a clean, odor-free environment on one (Bay Terrace) out of 4 nursing units. Findings include: Observations on the locked unit (Bay Terrace) revealed urine odors when entering the unit near rooms 501 and room [ROOM NUMBER]: - 9/20/18 around 10:00 AM. - 9/21/18 at 10:25 AM. - 9/24/18 around 10:05 AM. - 9/27/18 around 4:30 PM. - 9/28/18 at 8:45 AM: area where 3 wheelchairs were parked in the hallway and room [ROOM NUMBER] 9/28/18 around 8:50 AM - Interview with E10 (RN, UM) determined wheelchairs had scheduled cleaning and were to be wiped down by unit staff when soiled. E10 sent two CNAs to check on the wheelchairs and called housekeeping for room [ROOM NUMBER]. This findings was reviewed with E1 (NHA) and E2 (DON) during exit conference beginning at 2:30 PM. | 2020-09-01 |
| 1048 | 1048 | ATLANTIC SHORES REHABILITATION & HEALTH CENTER | 85037 | 231 SOUTH WASHINGTON STREET | MILLSBORO | DE | 19966 | 2018-09-28 | 842 | B | 0 | 1 | JOPU11 | Based on record review, interview and review of other facility documentation it was determined that the facility failed to ensure medical records were accurate for three (R129, R69 and R5) out of 54 sampled residents. Findings include: Cross Refer F684, Example 1. 1. Review of R129's clinical record revealed: 3/1/18 - admitted to facility for rehabilitation after breaking an ankle. March, (YEAR) - September, (YEAR) - Review of R129's eMARs, CNA documentation for bowel movements and bowel sheets obtained from E8 (LPN, UM) on 9/25/18 found: a. BMs documented on the bowel sheet but not in R129's clinical record: (MONTH) 26 and (MONTH) 18. b. PRN medication documented on the bowel sheet but not in the clinical record: (MONTH) 14 and 25. Findings revealed inaccurate documentation. 2. Review of R69's clinical record revealed: Review of nursing progress notes and incident reports for falls discovered a fall on 2/13/18 was not documented in the clinical record: - Nursing progress note written at 9:36 PM included R69 remained free from fall and injuries this evening. There was no description of the fall in the clinical record. - Review of a written statement by E24 (CNA) revealed while taking the resident to the toilet, R69 missed the toilet and landed on the floor. 9/25/18 (11:57 AM) - Interview with E24 to determine how the resident fell with the CNA present. E24 said R69 had lost his/her balance while turning, which was not reflected in the written statement. 9/25/18 (12:00 PM) - Interview with E8 (LPN, UM) located the IDT note describing the (MONTH) fall, but no nursing progress note then said I see what you are talking about after locating the RN assessment within the incident reporting system. Findings revealed incomplete and inaccurate documentation. 3. Review of R5's clinical record revealed: 3/4/16 - Care plan for fall risk (last revised 8/21/18) included the resident experienced a fall on 1/13/18 and 8/6/18. 3/13/18 - Annual MDS Assessment documented R5 was cognitively intact with a BIMS of 13 out of 15 and requ… | 2020-09-01 |
| 1237 | 1237 | BRACKENVILLE CENTER | 85042 | 100 ST. CLAIRE DRIVE | HOCKESSIN | DE | 19707 | 2018-04-11 | 565 | B | 0 | 1 | PNPC11 | Based on resident interviews and review of Resident Council Meeting minutes, it was determined that the facility failed to act promptly upon resident grievances concerning issues of food palatability, or to provide rationale for failure to act upon the grievances. Findings include: Review of Resident Council Meeting minutes revealed the following: 9/25/17 - Breakfast and coffee coming to residents rooms was cold. 10/30/17 - Hot drinks were not always hot and should be served with the meal. 11/27/17 - No food concerns noted. December (YEAR) - Resident Council Meeting canceled due to Norovirus. 1/25/18 - Hot foods are not always even warm, much less hot. Coffee was not always hot. 2/22/18 - Temperature of food continues to be an issue. Food served doesn't always match the menu posted. During the Resident Council Meeting with the surveyors and 17 residents on 4/15/18 at 2:30 PM, in response to the questions: Does the facility consider the views of the resident or family groups and act promptly upon grievances and recommendations? The resident group stated the biggest issue was the food and there have been problems for months. Does the Grievance Official respond to the resident or family group's concerns? The resident group stated the facility's reply was that they'll look into it. The resident group stated the food was cold, they are served food that was not on the menu, and the facility runs out of food. If the facility does not respond to concerns, does the Grievance Official provide a rationale for the response? The resident group stated they have not gotten any response regarding their concerns with the food, other than it's being looked into. On 4/11/18 at 11:52 AM, during an interview, E1 (NHA) stated his response to the grievance regarding the food was to have the Food Service Director meet with the resident group, but he had no documentaion to support that response. Findings were reviewed with E1 and E2 (DON) at the exit conference on 4/11/18. | 2020-09-01 |
| 1329 | 1329 | CADIA REHABILITATION CAPITOL | 85048 | 1225 WALKER ROAD | DOVER | DE | 19904 | 2017-05-26 | 244 | B | 0 | 1 | ST2M11 | Based on interview and review of other facility documentation it was determined the facility failed to respond promptly upon requests from the resident council. Findings include: August (YEAR) - (MONTH) (YEAR) - Review of Resident Council Meeting minutes documented the council requested that the bulletin boards and artwork be rehung in the activity room in August, September, October, November, (MONTH) and January. The facility provided no response to the repeated requests. - (MONTH) (YEAR) minutes documented the new Activities Director starts the following week. - (MONTH) (YEAR) minutes recorded E10 (Activity Director) to follow up with E1 (NHA) about which department head to address the residents' concern. - (MONTH) (YEAR) minutes indicated the bulletin board was up and in use. During an interview with R65 (Resident Council President) on 5/25/16 around 10:00 AM R65 stated that two bulletin boards in the activity room were removed when the wallpaper was put up. We asked for them to be returned for months. They threw everything out I guess. They said they had to get new ones. R65 said that E10 bought the new bulletin boards him/herself. During an interview with E10 on 5/25/17 at 11:00 AM, E10 confirmed s/he started at the facility in December, (YEAR) and discovered the residents had been asking for the bulletin boards and art work to be replaced in the activity room since last summer. E10 stated that s/he purchased the bulletin board since the facility had not responded to the request. It is not as big as they wanted, but at least they have one. During an interview with E1 on 5/25/17 at 1:55 PM to determine how resident council concerns or grievances are addressed, E1 said that E10 would do the concern form and go to the department head, get resolution and present it at the next meeting. When asked when the activity room renovation was completed, E1 responded after I started here (September (YEAR)). E11 (Corporate Nurse) who was in attendance, said it was old and was damaged during the renovation and confirmed the… | 2020-09-01 |
| 1352 | 1352 | CADIA REHABILITATION CAPITOL | 85048 | 1225 WALKER ROAD | DOVER | DE | 19904 | 2017-07-19 | 514 | B | 1 | 0 | SEW111 | > Based on a clinical record review and staff interviews, it was determined that the facility failed to consistently document required data on the scheduled toileting flowsheets for 1 (R2) out of 4 sampled residents based on R2's established toileting schedule/plan. Findings included: R2's clinical record reflected the following: Scheduled Toileting Flowsheets with set times each day to check/toilet and/or change R2 May (YEAR) - on at least 35 out of 156 occasions staff failed to document if R2 voided or not and whether R2 was wet or dry June (YEAR)- on at least 27 out of 155 occasions staff failed to document if R2 voided or not and whether R2 was wet or dry July (YEAR)- on at least 10 out of 34 occasions staff failed to document if R2 voided or not and whether R2 was wet or dry During an interview with the surveyor on 7/17/17 at 1:30 PM, E4 (CNA) stated that R2 was both continent and incontinent at times. R2 had a program to toilet, check and change R1. Staff is suppose to document according to the schedule. The surveyor interviewed E2 (DON) on 7/17/17 at 2:15 PM. E2 stated that R2's flowsheets were supposed to be filled out by staff and were not completed. During an interview with the surveyor on 7/17/17 at 2:25 PM, E3 (LPN-UM) stated that direct care staff are responsible for filling out the scheduled toileting flowsheet routinely. E2 acknowledged that R2's flowsheets shown to her by the surveyor were incomplete. The above findings were discussed at the exit conferences with E2 on 7/17/17 at 3:15 PM and again on 7/19/17 with E1 (NHA) and E2 at approximately 10:55 AM. | 2020-09-01 |
| 1725 | 1725 | NEWARK MANOR NURSING HOME | 08A020 | 254 WEST MAIN STREET | NEWARK | DE | 19711 | 2017-06-27 | 253 | B | 0 | 1 | 665M11 | Based on observations the facility failed to ensure that carpeting in resident areas were maintained in good repair. Findings include: During the observation periods from 6/19/17 through 6/23/17, between 10 AM and 4 PM and 6/26/17 to 6/27/17, between 10 AM and 4 PM, carpeted hallways from all three floors housing residents were found to have areas that were worn out, revealing frayed surfaces. Frayed surfaces were more noticeable on the second and third floors of the building, with damage to the carpet being observed at the entrance to the shower room on the second floor; in the hallway, and outside resident rooms 221 and 214. Carpeting was in disrepair in the activity room on the third floor and throughout the third floor hallway. These findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference on 6/27/17 at 2:15 PM. | 2020-09-01 |
| 1764 | 1764 | WESTON SENIOR LIVING CENTER AT HIGHFIELD | 85055 | 4800 LANCASTER PIKE | WILMINGTON | DE | 19807 | 2016-12-19 | 167 | B | 0 | 1 | 4IKO11 | Based on observation and interview it was determined that the facility failed to have reports from surveys, certifications and complaint investigations from the preceding 3 years available to review in an accessible location. Findings include: 12/7/16 at 9:25 AM - Observation during the initial tour found the following: - Survey binder contained only the (YEAR) survey results. - Survey binder was located by the reception desk on the rest residential side of the facility and not within the health center. - Signage explaining the location of the binder was in the foyer area of the health center and not readily visible to residents. During an interview with E3 (DON) on 12/16/16 at 12:30 PM the issues with the survey binder were discussed. E3 stated she would discuss with E1 (NHA). During an interview with E1 on 12/16/16 around 2:40 PM, E1 informed the surveyor the survey binder would be relocated to the health center, that the required additional surveys would be added and signage posted in an area visible to residents. These findings were reviewed with E1 and E3 on 12/19/16 at 2:00 PM. | 2020-06-01 |
| 1776 | 1776 | WESTON SENIOR LIVING CENTER AT HIGHFIELD | 85055 | 4800 LANCASTER PIKE | WILMINGTON | DE | 19807 | 2016-12-19 | 514 | B | 0 | 1 | 4IKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to ensure clinical records were accurate for three (R5, R11 and R13) of 23 stage 2 sampled residents and readily accessible and systematically organized for eight (R2, R3, R5, R9, R13, R20, R24 and R26) of 19 stage 1 sampled residents. Findings include: Inaccuracy 1. Review of R5's clinical record revealed the following inaccuracies: [NAME] (MONTH) (YEAR) - (MONTH) (YEAR) MARs - 8/20/16: 1 PRN med for pain signed off on the reverse but not on the front of the MAR. - 9/22/16: 1 PRN med for pain with correct information on reverse of MAR but signed under MOM on the front of the MAR. - 10/6/16: 1 PRN med for pain signed off under 9/22/16, but entry on reverse of the MAR was dated 9/21/16. B. 6/25/16 - R5 was readmitted to facility after hospitalization with multiple [DIAGNOSES REDACTED]. 6/30/16 - Handwritten physician order [REDACTED]. The indication (diagnosis) was not included in this order. December, (YEAR) POS and MAR documented the [DIAGNOSES REDACTED]. During an interview with E11 (LPN, medication administration nurse) on 12/15/16 around 10:50 AM when asked why the resident received the nasal spray, E11 stated it was calcium for bones. E11 confirmed the incorrect [DIAGNOSES REDACTED]. 2. Review of R11's clinical record revealed: 10/2/16 - Admission with a broken shoulder after a fall in the rest residential section of the facility. 10/5/16 - Physician order [REDACTED]. December, (YEAR) POS and MAR documented the incorrect [DIAGNOSES REDACTED]. 3. Review of R13's clinical record revealed: 2/9/16 - Physician order [REDACTED]. September, (YEAR) TAR - Missing the percentage of Boost pudding consumed on (MONTH) 1, 2, 5, 8, 9, 29 and 30. This finding was confirmed by E3 (DON) on 12/16/16 at 12:30 PM. Readily Accessible / Systematically Organized 4. During stage 1 locating the required weights for the residents (R2, R3, R5, R9, R13, R20, R24 and R26) who were admitte… | 2020-06-01 |
| 1809 | 1809 | REGAL HEIGHTS HEALTHCARE & REHAB CENTER | 85006 | 6525 LANCASTER PIKE | HOCKESSIN | DE | 19707 | 2016-03-31 | 253 | B | 0 | 1 | 3L3N11 | Based on observations and interviews on 3/22/16 and 3/23/16 during Stage 1 and during the environmental tour with E4 (FMD) on 3/28/16 between 9:45 AM and 11:00 AM , it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior for 17 rooms (A Wing: 11, 16, 21, 23, 26, 31, 32, 33; [NAME] Wing: 6, 7, 8; C Wing: 8; B Wing: 12, 16, 17, 24, 25) out of 36 rooms surveyed and 2 dining rooms (A and [NAME] wing dining rooms) . The following observations were made on 3/22/16 and 3/23/16 during Stage 1 review and during the environmental tour on 3/28/16 between 9:45 AM and 11:00 AM. Wing A Room 11 - The bedroom floor had streak marks at the entrance of the room; - Caulking around sink was in disrepair; - The sink was leaning down on the right side; Wing A Room 16 - The bathroom floor was dirty; - The bathroom smelled like urine; Wing A Room 21 - The bedroom floor and bathroom floor were dirty; - Two holes were in the bathroom wall by the mirror; - The bedroom walls had peeling paint; - The night stand had a knob missing on the third drawer; - The overbed table was dirty; - The wheelchair was dirty; Wing A Room 23 - The bedroom and bathroom floors were dirty; - Caulking around toilet in disrepair; - The bathroom wall was dirty to the right side of the sink; - Vent on the bathroom ceiling was dusty; - Walls in the bedroom around the bottom perimeter had peeling paint; - Wall under the window had chipped drywall; - Area under the A/C unit was dirty with debris; - The night stand had a knob missing on the first drawer; - The wheelchair was dirty; Wing A Room 26 - The bathroom floor around the edges and behind the toilet was not clean; - The baseboard cover was missing on the left side of the bathroom door; - The wall under the window had unsanded patches; Wing A Room 31 - The toilet seat was soiled; - The bucket to catch urine and feces had an area with dried brown material; Wing A Room 32 - The door surface facing the hallway was in… | 2020-02-01 |
| 1876 | 1876 | CADIA REHABILITATION BROADMEADOW | 85050 | 500 SOUTH BROAD STREET | MIDDLETOWN | DE | 19709 | 2017-01-31 | 514 | B | 1 | 0 | 820B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews and a review of a clinical record as well as other facility documents, it was determined that the facility failed to maintain clinical records specifically skin assessments and one medication record that reflected clear and/or accurately documented information for 1 (R7) of 8 sampled residents. Findings include: R7's skin integrity event record dated 1/15/17 showed that R7 had an open area on the sacrum which was documented to be a pressure wound. physician's orders [REDACTED]. The electronic treatment administration record (eTAR) for (MONTH) (YEAR) showed the above physician's orders [REDACTED]. The wound care nurse documentation dated 1/17/17 reflected that R7 had a pressure ulcer to the sacrum region. physician's orders [REDACTED]. The (MONTH) (YEAR) eTAR showed that the treatment as stated above was documented by staff as done every day from 1/18/17 until 1/31/17 rather then every 3rd day as ordered. During an interview on 1/31/17 at approximately at 1:45 PM with the surveyor, E5 (LPN) stated that staff do the dressing changes every 3 days but they are looking daily to make sure the dressing is still on and that no dressing change is needed. E5 who works on the unit full time confirmed that the treatment documentation on the (MONTH) eTAR did not accurately reflect that the treatment had been done every three days. Skin assessment completed by E6 (RN) on 1/19/17 documented the following: Is there any skin issue? Staff documented -No If yes (there is skin issues) list all skin issues. Staff documented- No new skin issues R7 did have a skin issue and was receiving treatments for a sacral pressure ulcer. Skin assessment completed by E6 on 1/26/17 documented the following: Is there any skin issue? Staff documented -No If yes (there is skin issues) list all skin issues. Staff documented- Treatment in place for a sacral tear As stated above the resident had a skin issue which was a pressure ulcer not a skin tear and R… | 2020-01-01 |
| 1888 | 1888 | GOVERNOR BACON HEALTH CENTER | 8e+29 | 2546 COLTER ROAD | DELAWARE CITY | DE | 19706 | 2017-01-11 | 253 | B | 0 | 1 | LHZ611 | Based on observation and interview it was determined that for 4 (107, 122, 132 and 209) out of 22 rooms reviewed, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior. Findings include: Observations were made during Stage 1 on 1/4/17 between 9:00 AM and 3:00 PM, on 1/7/17 between 9:00 AM and 1:00 PM and on 1/11/17 between 10:00 AM and 10:28 AM found: - 2 (107 and 209) rooms with moderate wall/door frame scuffing/peeling paint. - 1 (107) room with soiled privacy curtain. - 1 (122) room with moderate damage to baseboard. - 1 (132) room with severe staining on bathroom floor. - 1 (209) room with missing floor tile under sink. Findings were confirmed in interview with E8 (Maintenance Director) and E9 (Housekeeping Director) on 1/11/17 between 10:30 AM - 11:.00 AM. These findings were reviewed with E1 (NHA) and E2 (DON) on 1/11/17 at 3:00 PM . | 2020-01-01 |
| 1895 | 1895 | GOVERNOR BACON HEALTH CENTER | 8e+29 | 2546 COLTER ROAD | DELAWARE CITY | DE | 19706 | 2017-01-11 | 514 | B | 0 | 1 | LHZ611 | Based on record review and interview, it was determined that for two (R47 and R48) out of 24 sampled stage 2 residents the facility failed to maintain accurate and complete medical records. Findings include: Cross refer to F280 1. Review or R47's clinical record revealed: Review of R47's (MONTH) (YEAR) hourly safety check log revealed that on 12/16/16 from 10:00 AM through 2:00 PM and on 12/26/16 from 10:00 AM though 2:00 PM there were no signatures provided indicating that R47 was checked on by staff. During an interview on 1/10/17 at 2:29 PM with E10 (RN) charge nurse on R47's unit confirmed that R47 was checked on hourly by staff and that staff did not document the checks. Cross refer F323, example #1 2. Review of R48's clinical record revealed: November, (YEAR) PRN MAR indicated [REDACTED] - Two times when the date on the back of the MAR indicated [REDACTED] - Two administrations of the PRN anxiety medication were omitted on the back of the MAR (November 16 and 30). During an interview with E2 (DON) on 1/11/17 around 9:25 AM, E2 confirmed the inaccuracies. These findings were reviewed with E1 (NHA) and E2 on 1/11/17 at 3:00 PM. | 2020-01-01 |
| 1903 | 1903 | SHIPLEY MANOR | 85031 | 2723 SHIPLEY ROAD | WILMINGTON | DE | 19810 | 2016-10-03 | 253 | B | 0 | 1 | MZXC11 | Based on observations and interview, it was determined that the facility failed to ensure that all areas were clean and in good repair for 5 (500, 501, 502, 510, and 607) out of 28 resident rooms. Findings include: The following were observed during Stage 1 on 9/26/16 or 9/27/16 and on 9/28/16 between 10:00 AM and 10:35 AM during the Stage 2 environmental tour: Room 500 - A ceiling tile above the TV had a hole in it; - The molding by the corner of the wall near the bathroom door was scraped; Room 501 - Two screws were protruding from the wall by the TV; Room 502 - A ceiling tile above the recliner was not properly placed; Room 510 - There were two nails sticking out in the wall above A bed; - The bathroom wall across from the toilet was missing the towel bar; - The heater in the room was in disrepair; Room 607 - The air conditioning side panel was loose. Findings were reviewed and confirmed with E12 (FMD) on 9/28/16 at approximately 10:35 AM. Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), and E4 (Regional Nurse Consultant) on 10/3/16 at approximately 4:30 PM. | 2019-11-01 |
| 1970 | 1970 | THE MOORINGS AT LEWES | 85053 | 17028 CADBURY CIRCLE | LEWES | DE | 19958 | 2016-11-10 | 431 | B | 0 | 1 | IY2J11 | Based on record review and staff interview, it was determined that the facility failed to ensure that a system of records (Controlled Drug Count Sheet) kept for the receipt and disposition of all controlled medications was conducted by two licensed nurses at each shift change. This deficient practice was found on three out of three medication carts. Findings include: The facility policy entitled Narcotic Reconciliation, dated (MONTH) 2014, stated To ensure that the narcotic count at the end of each shift matches the amount of medication located in the blister packs .in each of the locked boxes on the medication carts. 1. The on going and off going charge nurses will count the narcotic together . 5. At the end of the count, both nurses will sign the count sheet stating the medications in the narcotic box coincide with the count on the sheets in the book . 11/03/16 at 9:00 AM - Review of the facility's Controlled Drug Count Sheet for three out of three medication carts from (MONTH) 1, (YEAR) through (MONTH) 31, (YEAR) revealed the facility failed to ensure that all controlled medications were counted by two nurses, the off-going nurse and on-coming nurse, at the end of each shift as follows: East Medication Cart: a total of 10 missing signatures for the on-coming and/or off going nurse. North Medication Cart: a total of 14 missing signatures for the on-coming and/or off going nurse. South Medication Cart: a total of 18 missing signatures for the on-coming and/or off going nurse. During an interview with E3 (ADON) on 11/4/16 at 12:00 PM, E3 confirmed these findings. The above findings were discussed at the exit conference on 11/10/16 at 3:00 PM with E1 (NHA) and E2(DON). | 2019-11-01 |
| 1973 | 1973 | WILLOWBROOKE COURT AT COUNTRY HOUSE | 85003 | 4830 KENNETT PIKE | WILMINGTON | DE | 19807 | 2016-05-26 | 253 | B | 0 | 1 | 9UA011 | Based on observations and interviews, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior for 4 (DW 7, DW 13 RG 2, and RG 16) out of 32 rooms surveyed. Findings include: On 5/20/16 during the Stage 1 review and during the environmental tour on 5/24/16 between 11:00 AM and 11:30 AM, the following were observed: Wing DW 7 - The front door did not close easily; Wing DW 13 - The walls in the bedroom and bathroom were scratched around the bottom perimeter; Wing RG 2 - The first drawer handle on the bedside table was missing; Wing RG 16 - The window sill on the left side was chipped; - The fire suppression sprinkler cap above the night table was loose. Findings were reviewed and confirmed with E7 (FMD) on 5/24/16 at approximately 11:30 during the environmental tour. Findings were reviewed during the exit conference on 5/26/16 at approximately 4:20 PM with E1 (ED), E2 (NHA) and E3 (DON). | 2019-10-01 |
| 2075 | 2075 | MILFORD CENTER | 85010 | 700 MARVEL ROAD | MILFORD | DE | 19963 | 2016-09-09 | 253 | B | 0 | 1 | LD9311 | Based on observations and interview, it was determined that for 7 (106, 122, 123, 216, 221, 233 and 312) out of 30 rooms reviewed, the facility failed to provide maintenance services necessary to maintain a sanitary, orderly and comfortable interior. Findings include: Observations were made during Stage 1 on 09/01/16 and 09/02/16 between 8:00 AM and 4:00 PM and on an environmental tour on 09/08/16 between 9:50 AM and 11:15 AM. - 4 (122, 216, 221, and 233) rooms with wall damage - 2 (106 and 123) rooms with door damage - 1 (122) room with a loose towel rack - 1 (312) room with a toilet issue (water in the toilet ran constantly). Findings were reviewed with E14 (FMD) on 9/9/16 at 9:10 AM. These findings were reviewed with E1 (NHA) and E2 (DON) on 9/9/16 at 3:00 PM. | 2019-08-01 |
| 2093 | 2093 | STONEGATES | 85026 | 4031 KENNETT PIKE | GREENVILLE | DE | 19807 | 2016-06-30 | 253 | B | 0 | 1 | 6NV411 | Based on observation and interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 8 rooms (Room 194, 207, 216, 217, 218, 221, 222, and 228) out of 29 rooms. Findings include: The following was found during the environmental tour on 6/28/16 from 10:30 AM to 11:00 AM as well as during stage 1, on (MONTH) 27, (YEAR): Room 194 - The ceiling light by the window was out; Room 207 - The shower stall light was not working; Room 216 - The bathroom baseboard next to the shower wall had a missing section; Room 217 - The toilet had 1 missing toilet bolt cover on the left side; Room 218 - The ceiling tile above the closet was stained; Room 221 - The toilet bolts were exposed; Room 222 - 3 ceiling tiles next to the left wall has a water stain; Room 228 - 3 ceiling tiles next to the closet had a water stain. E4 (FMD) was interviewed and confirmed the findings on 6/28/16 at approximately 11:00 AM. Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference on 6/30/16 at approximately 3:15 PM. | 2019-08-01 |
| 2132 | 2132 | CADIA REHABILITATION BROADMEADOW | 85050 | 500 SOUTH BROAD STREET | MIDDLETOWN | DE | 19709 | 2016-05-27 | 514 | B | 0 | 1 | 56TL11 | Based on record review and interview it was determined that the facility failed to ensure the accuracy of clinical records for 2 (R6 and R168) out of 46 sampled residents in the areas of urinary continence (R6) and refusing to eat (R168). Findings include: 1. Review of R6's clinical record revealed: February (YEAR) through (MONTH) (YEAR) -Review of Scheduled Toileting Flowsheet and urinary entries on the CNA flowsheet found discrepancies when the toileting flowsheet documented incontinence on the 3:00 PM - 11:00 PM shift while the CNA flowsheet recorded the resident was continent. The following dates and times show the inconsistencies: February (YEAR) - 6 times (2/1, 2/2, 2/4, 2/5, 2/6 and 2/7) March (YEAR) - 7 times (3/7, 3/8, 3/9, 3/10, 3/11, 3/12 and 3/27) April (YEAR) - 11 times (4/3, 4/4, 4/5, 4/14, 4/15, 4/23, 4/24, 4/25, 4/26, 4/27 and 4/30) May (YEAR) 13 times (5/3, 5/4, 5/9, 5/10, 5/11, 5/12, 5/13, 5/14, 5/15, 5/17, 5/18, 5/19 and 5/20) There were 37 out of 114 evening shifts with inaccurate documentation of R6's continence between 2/1/16 - 5/24/16. During an interview with E17 (RN, UM) on 5/25/16 at 10:24 AM to review the toileting and CNA flowsheets, E17 confirmed the documentation discrepancies. 2. Review of R186's clinical record revealed: March (YEAR) and (MONTH) (YEAR) - Review of Food Intake Record and refusing to eat entries on the Behavior Administration History log found discrepancies when the Food Intake Record documented that R186 refused to eat a meal while the behavior monitoring sheet documented that there were no times that the resident refused to eat. March (YEAR) -3 times (3/7 dinner, 3/9 breakfast, and 3/11 dinner). April (YEAR) -2 times (4/6 breakfast and 4/13 lunch). During an interview with E18 (RN) on 5/27/16 at 9:40 AM, E18 confirmed the documentation discrepancies. These findings were reviewed with E1 (NHA) and E2 (DON) on 5/27/16 at 1:35 PM. | 2019-08-01 |
| 2156 | 2156 | SEAFORD CENTER | 85015 | 1100 NORMAN ESKRIDGE HIGHWAY | SEAFORD | DE | 19973 | 2016-03-28 | 244 | B | 0 | 1 | JCT011 | Based on review of facility documentation and interviews, it was determined that the facility failed to act upon 2 grievances of the resident council group affecting linens and assistance in the dining room. These concerns related to the Resident Council Meeting minutes were found. Findings include: On 3/22/16 at 9:30 AM, during an interview with R100 (Resident Council President for the past several years), R100 informed the surveyor of unresolved grievances in the area of linen and dining room assistance, as well as concerns related to the meeting minutes: 1. Linens: R100 stated there has been an ongoing battle between residents and staff for several years about residents getting clean towels and wash cloths. R100 said that residents want a clean towel and wash cloth every morning but many days that does not happen, as recently as 3/20/16. R100 stated the facility said residents were hoarding linens, but she knows of only two residents who hoard linens. R100 added that residents who cannot go and get their own linen are often not getting clean linen when they ask. Review of resident council meeting minutes from September, (YEAR) through March, (YEAR) revealed: - 9/11/15: old business stated shortage of linen is an ongoing issue. Solution by E1 (NHA) was We are still finding linen in resident rooms. - 10/14/15: old business stated residents discussed the towel and wash cloth shortage. E1's solution was that E1 would speak with housekeeping staff. - 11/6/15: there was no evidence of follow-up on the linen issue and minutes did not say it was resolved. - 12/4/15: Residents would like to have one towel and one wash cloth in the morning for each person. E1's solution included that E1 would in-service staff again, but if they (resident) should need one please ask the aide or nurse. - 1/15/16: When staff take out a dirty wash cloth or towel, can they replace them at that time and not wait until the next day. E1 wrote under solution that she in-serviced about the towels and wash cloths so from this point on I (E1) need … | 2019-07-01 |
| 2289 | 2289 | DELAWARE VETERANS HOME | 85051 | 100 DELAWARE VETERAN'S DRIVE | MILFORD | DE | 19963 | 2015-10-14 | 253 | B | 0 | 1 | JOZU11 | Based on observation and interview it was determined that the facility failed to maintain housekeeping and maintenance services for 7 (1060, 1207, 1210, 1211, 1274, 1275, 1277) out of 15 rooms reviewed in the facility. Findings include: Observations during the initial tour on 10/6/15 and the environmental tour on 10/12/15 between 10:00 AM - 11:00 AM revealed -Room 1060-2 scuff marks on lower right wall below chair rail -Room 1207-1 fall mats with frayed corners, limited the ability to clean, dried tan spot around 3 inches in diameter on one mat, white discoloration widespread over majority of the mats, upper side rail by window with numerous brown and tan spots -Room 1210-1 lower section of small wall with drywall damage -Room 1211-1 outside of bathroom door with horizontal scrape near bottom; paint on headboard; brown stains on side rail -Room 1274-1 black stains on floor near toilet -Room 1275-2 dirty floor in sleeping/living area; bathroom floor and vanity dirty -Room 1277-2 marks on bottom of closet door several vertical scratches/damage to wall at head of bed These findings were reviewed with E16 (Maintenance Supervisor) on 10/14/15 at 8:30 AM and with E1 (NHA) and E2 (acting DON) on 10/14/15 at 3:30 PM. | 2019-03-01 |
| 2347 | 2347 | COURTLAND MANOR | 85019 | 889 SOUTH LITTLE CREEK ROAD | DOVER | DE | 19901 | 2016-02-03 | 253 | B | 1 | 0 | 9EQH11 | > Based on observation it was determined that the facility failed to provide housekeeping and maintenance services for 8 (308, 313, 317, 321, 327, 404, 410, and 418) out of 28 rooms. Findings include: Observations during Stage 1 (01/28/16 and 01/29/16 from 7:30 AM to 4:00 PM) and on an environmental tour on 02/02/16 from 11:48 AM to 12:03 PM and revealed the following: -Rm 308 - laminate broken off the left side of the sink counter -Rm 313 - laminate broken off the left side of the sink counter -Rm 317 - laminate peeling off of the sink counter -Rm 321 - laminate peeling off of the sink counter front and left side -Rm 327 - laminate peeling off of the sink counter front and left side -Rm 404 - towel bar mounted on the sink counter is loose -Rm 410 - rust stain on back left corner of the sink, separation of the caulk around the sink, and towel bar mounted on the sink counter is loose -Rm 418 - rust stain on back left corner of the sink, separation of the caulk around the sink, and the towel bar mounted on the sink counter is loose Findings were reviewed with E1 (NHA) on 02/03/16 at 11:10 AM. Findings were also reviewed with E1 and E2 (DON) on 02/03/16 at 2:30 PM. | 2019-02-01 |
| 2356 | 2356 | HARBOR HEALTHCARE & REHAB CTR | 85034 | 301 OCEAN VIEW BLVD | LEWES | DE | 19958 | 2016-07-01 | 253 | B | 0 | 1 | ES1H11 | Based on observations and interview, it was determined that for 9 (124, 126, 131, 201, 209, 214, 263, 302 and 309) out of 36 rooms reviewed, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior. Findings include: Observations were made during Stage 1 on 06/24/16 and 06/27/16 between 8:00 AM and 4:00 PM, 06/30/16 between 11:00 AM and 11:20 AM and 07/01/16 between 9:25 AM and 9:55 AM. - 5 (201, 209, 214,302 and 309) rooms with loose towel bars. - 2 (126 and 131) rooms with loose bathroom sinks. - 1 (201) room with furniture in poor repair. - 2 (124 and 263) rooms with soiled privacy curtains. Findings were confirmed in interview with E5 (FMD), E31 (Regional Director of Operations) and E32 (Environmental Director) 07/01/16 at 10:55 AM. These findings were reviewed with E1 (NHA) and E2 (DON) on 7/1/16 at 3:15 PM . | 2019-02-01 |
| 2390 | 2390 | PINNACLE REHABILITATION & HEALTH CENTER | 85020 | 3034 SOUTH DUPONT HIGHWAY | SMYRNA | DE | 19977 | 2015-08-25 | 253 | B | 0 | 1 | QQL511 | Based on observations and interview, it was determined that for 5 (110, 226, 309, 329, and 336) out of 36 rooms reviewed the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior. Findings include: Observations noted in stage 1 from 8/17/15 through 8/19/15 (8:00 AM - 4:00 PM were verified by E8 (FMD) on 08/24/15 between 11:20 AM and 11:50 AM. The following were observed: - loose towel bars in the bathrooms of rooms 110 and 329 - wall, doorway, and/or baseboard damage in bathrooms of rooms 309, 329, and 336 - loose plumbing fixtures on a sink in room 226 All findings were reviewed and confirmed by E8 during the environmental tour on 08/25/15 from 9:30 AM to 9:40 AM. These findings were reviewed with E1 (NHA) and E2 (DON) on 8/25/15 at 2:30 PM. | 2019-01-01 |
| 2664 | 2664 | SEAFORD CENTER | 85015 | 1100 NORMAN ESKRIDGE HIGHWAY | SEAFORD | DE | 19973 | 2015-02-20 | 253 | B | 0 | 1 | HTRU11 | Based on observations during the environmental tour with E6 (Environmental Services Director) on 2/20/15 between 10:55 AM - 11:15 AM, it was determined that the facility failed to provide maintenance services necessary to maintain an orderly and comfortable interior. Findings include: 1. Ball/end missing on the end of the bathroom emergency call light cord in room 121 shared by two residents. The ball/end makes it easier for residents with limited finger dexterity to pull/activate the emergency cord. 2. Horizontal wall trim behind beds in rooms 120A, 222B and 230B were broken. E6 stated the broken trim may be due to raising the bed while the bed is close/against the wall. E6 stated that repair would include either replacement or removal of the trim. 3. Significant drywall damage in rooms 101 (next to window), 124 (next to window- spackling applied, awaiting sanding and repainting), 221 (next to window), and 225 (below paper towel dispenser). E6 stated that the areas required spackling, sanding and repainting. 4. The interior of the bathroom door in room 124 has thinned and missing paint making the door unaesthetic. 5. Toilet seat in room 117 was extremely worn with dark discoloration due to wearing of the finish. E6 stated that the toilet seat needed to be replaced. 6. Significant dark grey floor scuffing (two areas approximately 8 inches in width that ran the entire length of the room from the doorway to the far wall) in room 202. E6 stated that the scuff marks were from a resident's walker and the floor needed to be stripped and polished. All findings were confirmed with E6 during the environmental tour on 2/20/15 from 10:55 AM- 11:15 AM. | 2018-08-01 |
| 2691 | 2691 | WILLOWBROOKE COURT AT COKESBURY VILLAGE | 85017 | 726 LOVEVILLE ROAD | HOCKESSIN | DE | 19707 | 2015-02-25 | 241 | B | 0 | 1 | V7QB11 | Based on observations and interviews, it was determined that the facility failed to care for residents in a manner and in an environment that maintains or enhances each resident's dignity for three (R28, R48 and R60) out of 27 Stage 2 sampled residents. On two (2) separate dining observations nursing students were observed feeding and/or assisting the residents while wearing disposable gloves. Findings include: On 2/19/15 from 12:00 PM through 12:45 PM, in the assisted dining room, the following observations were made: 1. R48 was assisted during the midday meal by S1, who was wearing disposable gloves. The facility failed to ensure R48 was cared for in a dignified manner. 2. R60 was assisted during the midday meal by S2, who was wearing disposable gloves. Additionally on 2/24/15 from 12:00 PM through 12:48 PM, S2 was again observed assisting R60 during the midday meal while wearing disposable gloves. The facility failed to ensure R60 was cared for in a dignified manner. 3. R28 was assisted during the midday meal by S3, who was wearing disposable gloves. Additionally on 2/24/15 from 12:00 PM through 12:48 PM, S3 was again observed assisting R28 during the midday meal while wearing disposable gloves. The facility failed to ensure R28 was cared for in a dignified manner. On 2/25/15 at 8:30 AM in an interview, I1 (Nursing Student's Instructor), with regards to all the above examples, stated that the practice of the school was to have students wear gloves only when giving direct resident care. It was not the practice of the school to have the students use gloves while they are feeding the residents. I1 stated they were instructed by the facility to err on the side of caution and have the students wear gloves just in case they would be handling the food. On 2/25/15 at 12:38 PM, E5 (DCS) confirmed that he suggested the students wear gloves to prevent bare hand contact with the food. E5 stated he saw a potential situation where a student could possibly touch an egg salad sandwich, so he interceded and suggested the glove… | 2018-07-01 |
| 2699 | 2699 | CHURCHMAN VILLAGE | 85025 | 4949 OGLETOWN-STANTON ROAD | NEWARK | DE | 19713 | 2015-01-07 | 253 | B | 0 | 1 | WFWF11 | Based on observations and interviews made in resident rooms during the survey, it was determined that the bathroom doors, room walls and over bed light cords for eight (8) out of 35 rooms reviewed did not have adequate maintenance services. Findings include: 1. Observation on 12/17/14 at 3:00 PM of room E125B revealed the over bed light cord was too short. 2. Observation on 12/17/14 at 3:01 PM of room W123B revealed the walls in the bathroom had peeling paint and the over bed light cord was too short. 3. Observation on 12/18/14 at 8:50 AM of room E105 revealed scrapes on the inside of the bathroom door at the bottom, and along the wall in front of the toilet. 4. Observation on 12/18/14 at 9:15 AM of room E120 revealed scrapes on the inside of the bathroom door at the bottom. 5. Observation on 12/18/14 at 10:35 AM of room W122 revealed peeling paint on the left wall when entering the room. 6. Observation on 12/18/14 at 11:04 AM of room W102 revealed walls with peeling paint and a wall in disrepair by the heating/air conditioning unit. 7. Observation on 12/18/14 at 11:41 AM of room E111 revealed a scraped wall and chipped paint in front of the bathroom toilet. 8. Observation on 12/18/14 at 11:51 AM of room W109 revealed the left wall, when entering the room, had peeling paint. The above listed findings were confirmed by E5 (Environmental Services Director) during an interview during the environmental tour on 12/22/14 at approximately 2:30 PM. | 2018-07-01 |
| 2733 | 2733 | MILTON & HATTIE KUTZ HOME | 85043 | 704 RIVER ROAD | WILMINGTON | DE | 19809 | 2014-12-15 | 170 | B | 0 | 1 | XUDR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and review of the facility mail delivery system, it was determined that the facility failed to provide mail delivery to residents on Saturdays. Findings include: On 12/3/14 at 2:00 PM, an interview with R44 revealed that residents do not receive mail on Saturdays. R44 stated that during the week mail is delivered to your room, but if mail comes on Saturdays, it is delivered to the front desk. R44 stated that unless she went to the front desk on Saturdays, she would not get Saturdays mail until Monday. During an interview on 12/9/14 at 9:30 AM with E20 (Receptionist), a [AGE] year employee of the facility, she stated that the mail delivery system has been the same since she has been here. E20 works Monday-Friday 8 AM - 4:30 PM, and on the weekend various part-time staff work from 8 AM - 8 PM. E20 stated that mail is delivered once a day to the facility from Monday to Saturday. When asked by the surveyor what the normal routine was once mail was delivered to the facility, E20 stated that she sorts out the mail. She then places resident mail into a bin and then someone from the activities department picks up the mail from the bin and delivers it to the residents. E20 stated on Saturday there were no activity personnel in the facility, so mail is not delivered to the residents until Monday. The facility's mail delivery system failed to ensure residents received mail on Saturdays. Findings were reviewed with E1 (NHA) and E2 (DON) on 12/15/14 at approximately 4:20 PM. | 2018-07-01 |
| 2755 | 2755 | WILLOWBROOKE COURT SKILLED CENTER AT MANOR HOUSE | 85009 | 1001 MIDDLEFORD ROAD | SEAFORD | DE | 19973 | 2015-01-28 | 253 | B | 0 | 1 | 3T4H11 | Based on observations throughout the survey, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain an orderly and comfortable interior. Findings include: Observations during the tour of the facility on 1/20/15, and 1/21/15 (between the hours of 9:00 AM and 3:00 PM) revealed the following concerns: 1. Observation of room 15 on 1/20/15 at 1:39 PM revealed that an area on the wall behind the recliner had multiple scrapes in the wall, areas of missing paint, and what appears to be water damage near the heating vent. 2. Observation of room 3 on 1/21/15 at 9:39 AM revealed a small hole in the bathroom wall near the light switch. 3. Observation of room 25 on 1/21/15 at 10:54 AM revealed damage from wheelchair traffic to the bathroom door. 4. Observation of room 40 on 1/21/15 at 11:21AM revealed scrapes to the bathroom door consistent with damage from wheelchair traffic, and disrepair of the trim/protective covering of the door. 5. Observation of room 41 on 1/21/15 at 11:47AM revealed wall damage behind the entrance door and removal of the finish covering the bathroom cabinet. Findings were reviewed with E1, NHA and E2 DON on 1/28/15 at 2:30 PM. | 2018-05-01 |
| 2883 | 2883 | FORWOOD MANOR | 85036 | 1912 MARSH ROAD | WILMINGTON | DE | 19810 | 2014-09-18 | 356 | B | 0 | 1 | NL9E11 | Based on review of facility documents and interview, it was determined that the facility failed to post on a daily basis the total number of hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. Findings include: Review of the facility's daily staff posting during the survey from 9/10/14 through 9/17/14 revealed the absence of the total number of hours worked by the nursing staff. In an interview on 9/17/14 at 9:04 AM, E1 (NHA) confirmed the finding. | 2018-02-01 |
| 2917 | 2917 | SILVER LAKE CENTER | 85027 | 1080 SILVER LAKE BLVD | DOVER | DE | 19904 | 2014-09-04 | 253 | B | 0 | 1 | T7W011 | Based on observations made in resident rooms during the survey, it was determined that the bathroom doors of eleven out of sixty six rooms reviewed did not have adequate maintenance services. Findings include: 1. On 08/27/14, the bathroom doors of the following rooms were observed with paint scuffs and scrapes from wheel chair traffic; 123, 124, 125, 127, 128, 130, 131, 218, and 229. 2. On 09/03/14, the following additional rooms were observed with paint scuffs and scrapes from wheel chair traffic; 102 and 211. Findings were reviewed with E1, NHA, on 09/04/14. | 2017-12-01 |
| 3150 | 3150 | HARRISON SENIOR LIVING OF GEORGETOWN, LLC | 85029 | 110 W. NORTH STREET | GEORGETOWN | DE | 19947 | 2014-02-03 | 167 | B | 0 | 1 | OYNC11 | Based on observation and interview it was determined that the facility failed to enure that the results of the most recent survey was posted in an area accessible to all residents. The facility also failed to post a notice of the availability of the survey results. Findings include: On 1/29/14 at approximately 2 PM - Observation revealed the survey results nor a notice of availability were found in the front lobby or other common areas of the facility. On 1/30/14 at approximately 11 AM - Observation revealed there was no notice of the availability of the survey results found on the three residential units or the common areas in the facility. On 1/30/14 at approximately 11:30 AM - Observation of the survey results were found on the Sussex unit to be in a clear plastic holder attached to the wall that was mounted over 4 feet high. This was not accessible to residents confined to a wheelchair. There were no survey results posted in the Rehabilitation unit or common areas of the facility. The(NAME)unit results were posted in a manner that was accessible to their residents. On 1/31/14 - Interview at 2:45 PM with the Administrator, E1, and Assistant Director of Nursing, E3, confirmed the above observations. | 2017-07-01 |
| 3175 | 3175 | CADIA REHABILITATION CAPITOL | 85048 | 1225 WALKER ROAD | DOVER | DE | 19904 | 2014-08-01 | 159 | B | 0 | 1 | ODAO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interviews, it was determined that the facility failed to have reasonable access after hours to resident's personal funds, that were being managed by the facility. Findings include: The facility provided an undated policy that addressed management of residents' funds after business hours whose purpose it listed to ensure residents who participate in the process have round the clock access to their funds. The policy's protocol states that: 1. The nursing supervisor will be responsible for assisting residents with obtaining their personal funds on weekends, holidays, and evenings. 2. Residents are informed of the process for accessing funds as part of the admission process and personally by the business office when completing Resident Fund paperwork. In a resident interview on 7/28/14 at 9:09AM with R25, during Stage I of the survey process, R25 stated that I can only get money when the lady is here. This interview revealed that the resident was unaware of how to obtain her personal funds during non-business hours, including weekends. During an interview on 7/30/14 at 11:10AM with E1, NHA he stated that he looked back an entire year and found no receipts of residents requesting money from their personal funds account with the facility. This look back included after hours and Saturdays and Sundays. E1 then stated that the receptionist does have petty cash that residents could fill out a slip for to request money. During an interview with E10, RN, Unit Manager on 7/30/14 at 11:45AM, an employee of the facility since 1999, who works occasionally between 3PM -11PM and the weekends, she stated she was unaware that supervisors had access to money in the case that a resident would request it during off hours. She stated that they would have to wait until someone was present in the office during the day. A [AGE] year employee of the facility and [AGE] year Supervisor, E11 RN, was also interviewed. On 7/31/14 at 7:56 AM, E11 … | 2017-07-01 |
| 3217 | 3217 | NEW CASTLE HEALTH AND REHABILITATION CENTER | 85039 | 32 BUENA VISTA DRIVE | NEW CASTLE | DE | 19720 | 2014-03-07 | 253 | B | 0 | 1 | X61C11 | Based on observations in the resident rooms during the survey, it was determined that the facility failed to repaint scraped bathroom walls for six (202, 211, 406, 409, 505, 602) out of 40 rooms reviewed and repair damaged grout around bathroom vanities for three (103, 300, 311) out of 40 rooms reviewed. Findings include: 1. The interior walls of the bathrooms of the following rooms were observed to have scratched and scraped paint due to wheelchair traffic: - 202, adjacent to the vanity. - 211, adjacent to the toilet and adjacent to the door. - 406, adjacent to the door. - 409, along the wall. - 505, adjacent to the door. - 602, adjacent to the toilet. Findings were reviewed with E1, Administrator, on 3/07/14 at approximately 1:15 PM. 2. The vanities in the bathrooms of the following rooms were observed to have grout damage around the units attached to the wall: - 103. - 300. - 311. Findings were reviewed with E1, Administrator, on 3/07/14 at approximately 1:15 PM. | 2017-05-01 |
| 3232 | 3232 | CADIA REHABILITATION BROADMEADOW | 85050 | 500 SOUTH BROAD STREET | MIDDLETOWN | DE | 19709 | 2014-04-02 | 253 | B | 0 | 1 | HUWM11 | Based on environmental observations made in the residents' bathrooms throughout the survey, it was determined that the facility failed to provide maintenance services necessary to keep a comfortable and orderly interior for 9 (101, 104, 105, 107, 109, 113, 202, 301, 314) out of 45 rooms reviewed. Findings include: 1. The flooring in the resident bathrooms was cracked along the chamfered surface between the floor and the wall, adjacent to the bathroom sink. This was observed in 6 out of 45 rooms reviewed. The following rooms were effected: ? 104 ? 105 ? 107 ? 202 ? 301 ? 314 2. The paint in the resident bathrooms was scuffed from wheelchair traffic along the wall adjacent to the bathroom sink. This was observed in 4 out of 45 rooms reviewed. The following rooms were effected: ? 101, the paint in this bathroom was also flaking off of the wall. ? 105 ? 109 ? 113 On 4/2/14 at 11:30 AM the above information was reviewed with E1, Administrator, E2, Director of Nursing and E3, Assistant Director of Nursing. | 2017-05-01 |
| 3267 | 3267 | CHURCHMAN VILLAGE | 85025 | 4949 OGLETOWN-STANTON ROAD | NEWARK | DE | 19713 | 2014-02-12 | 253 | B | 0 | 1 | TXCT11 | Based on observations in the resident rooms during the survey, it was determined that the facility failed to repaint scraped bathroom doors for eight out of fourteen rooms reviewed. Findings include: The interior surfaces of the bathroom doors of the following rooms were observed to have scratched and scraped paint due to wheelchair traffic: ? E102 ? E103 ? E117 ? E123 ? E125 ? W105 ? W114 ? W118 Findings were reviewed with E9, Maintenance Director, on 2/12/14 at 10:15 AM. | 2017-04-01 |
| 3289 | 3289 | GILPIN HALL | 85047 | 1101 GILPIN AVENUE | WILMINGTON | DE | 19806 | 2013-12-19 | 371 | B | 0 | 1 | C9XQ11 | Based on observations and interviews, it was determined that the facility failed to store, prepare, distribute and serve food under sanitary conditions, with regard to storing wet food pans, a cracked slicer component and a wire whip for a table mixer that was in disrepair. Findings include: 1. Observation of the kitchen area on 12/11/2013 at 2:35 PM revealed a ready-to-use storage rack with three stacks of three steam table pans each that were dripping wet. On 12/11/13 at 2:40 PM, E9 (Assistant Director of Food and Nutrition) separated the pans and confirmed this finding. 2. Observation of the kitchen area on 12/11/2013 at 2:45 PM revealed a food slicer component with a crack by the handle. The cracked component was not cleanable. On 12/12/2013 at 8:25 AM, E8 (Director of Food and Nutrition Services) stated the component would be replaced. 3. Observation of a table mixer in the kitchen area on 12/11/2013 at 2:47 PM revealed that the wire whip was in disrepair. On 12/11/2013 at 2:48 PM, findings were discussed with E9. | 2017-04-01 |
| 3301 | 3301 | MILLCROFT | 85021 | 255 POSSUM PARK ROAD | NEWARK | DE | 19711 | 2013-11-06 | 156 | B | 0 | 1 | 571711 | Based on record review and staff interview, it was determined the facility failed to provide the Notice of Medicare non coverage letter with the Rights to Appeal this decision to two (R123 and R156) out of three sampled residents. Findings include: 1. Review of facility records, lacked evidence that the Notice of Medicare non coverage letter with the Right to Appeal this decision was provided to R123, when this resident was discharged from the facility. On 10/31/13 at 12:34 PM, E4 (Social Service Director) stated that she thought she had provided the Notice of Medicare non coverage with the Rights to Appeal letter to R123 and would look further for it. As of 11/4/13, facility lacked evidence of the Notice of Medicare non coverage letter with the Right to Appeal this decision for R123. 2. Review of facility records, lacked evidence that the Notice of Medicare non coverage letter with the Right to Appeal this decision was provided to R156, when this resident was discharged from the facility. On 10/31/13 at 12:34 PM, E4 (Social Service Director) stated that she thought she had provided the Notice of Medicare non coverage with the Rights to Appeal letter to R156 and would look further for it. As of 11/4/13 at 2:32 PM, facility lacked evidence of the Notice of Medicare non coverage letter with the Right to Appeal this decision for R123. Review of a spreadsheet entitled, CMS Medicare Notices, SNF-Medicare A/B/MC October 2013, was provided by E1(Administrator), documented when to give the notice to residents. It indicated that when a resident simultaneously ends coverage under Part A and is discharged , the Notice of Medicare provider Non-Coverage is to be given. The facility failed to provide the Notice of Medicare non coverage letter with the Rights to Appeal this decision to two (R123 and R156) out of three sampled residents. | 2017-03-01 |
| 3389 | 3389 | DELAWARE VETERANS HOME | 85051 | 100 DELAWARE VETERAN'S DRIVE | MILFORD | DE | 19963 | 2013-09-25 | 372 | B | 0 | 1 | 87PG12 | Deficiency Text Not Available | 2017-02-01 |
| 3438 | 3438 | SILVER LAKE CENTER | 85027 | 1080 SILVER LAKE BLVD | DOVER | DE | 19904 | 2013-09-12 | 364 | B | 0 | 1 | XWR511 | Based on observations and interview it was determined that the facility failed to provide food with a texture the residents could chew for 8 (R146, R58, R242, R238, R23, R36, R239 and R141) out of 41 sampled residents . Findings include: On 9/4/13 at 12:15 PM through 1:05 PM a dining observation was completed in the Bistro (main dining room). The facility provided a diet of oven baked pork with sweet potatoes and cabbage. Residents were observed complaining they were having difficulty chewing and cutting the pork. The following residents complained that the pork was too tough to cut and chew and asked the surveyor to come and look at the pork: R146, R58, R242, R238, R23, R36, R239 and R141. Findings were reviewed with E1, Administrator, E17, Director of Food Service and E18, Chef Manager on 9/12/13 at 11:10 PM. | 2017-01-01 |
| 3522 | 3522 | MILFORD CENTER | 85010 | 700 MARVEL ROAD | MILFORD | DE | 19963 | 2012-09-25 | 356 | B | 0 | 1 | P7I111 | Based on observation on the Homestead Unit on 9/18/12, it was determined that the facility failed to post the nurse staffing information that was readily accessible to residents and visitors and in a readable form. Findings include: 1. At 9:45AM, the staff posting for the Homestead unit was stored in a folder behind the desk at the nurse's station. | 2016-11-01 |
| 3807 | 3807 | CADIA REHABILITATION BROADMEADOW | 85050 | 500 SOUTH BROAD STREET | MIDDLETOWN | DE | 19709 | 2013-06-12 | 253 | B | 0 | 1 | LUMO11 | Based on observations made during the environmental tour of the facility with E10 (Maintenance Director), it was determined that the facility failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior, with regards to debris on the ventilation window units in eight residents rooms, and heavy dust on the ventilation coil of two resident room ventilation units. Findings include: 1. Observations made during the environmental tour of the facility with E10 (Maintenance Director) on 6/11/13, at approximately 10:45 AM, revealed heavy food, plant and other debris on the window vent screens of the following resident rooms: 113, 209, 214, 221, 224, 303, 312, and 313. 2. Observations made during the environmental tour of the facility with E10 (Maintenance Director) on 6/11/13, at approximately 10:45 AM, revealed heavy dust on the window ventilation unit coils when the covers were removed in resident rooms 209 and 221. On 6/11/13 at 11:33 AM, E10 confirmed that a ventilation contractor would be cleaning the coils of the ventilation units for all resident rooms at the facility today. | 2016-07-01 |
| 3929 | 3929 | DELMAR NURSING & REHABILITATION CENTER | 85041 | 101 E. DELAWARE AVENUE | DELMAR | DE | 19940 | 2013-05-10 | 514 | B | 1 | 0 | 7GRS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that for two (R4 and R10) out of 17 sampled resident the facility failed to ensure accurately documented and systematically organized clinical records. Findings include: 1. Review of R4's clinical record revealed the following physician telephone/verbal orders that were never signed by the physician (MD) or designee; - On 9/4/12 Send to ER for eval (evaluation) ordered by E32, nurse practitioner (NP) and written by E6, registered nurse (RN). There was no time on the order and it was never signed by NP or MD. - On 8/29/12 Obtain culture from scrotum drainage ordered by E13, NP to E29, RN. There was no time on the order and it was never signed by NP or MD. - On 8/10/12 DC (discontinue) weekly vital signs change to weekly BP (blood pressure) and pulse ordered by E5, MD to E18, LPN .There was no time on the order and it was never signed by NP or MD. These findings were confirmed by interview on 5/10/13 at 2 PM with E1, Administrator and E2, Director of Nursing. 2. When reviewed on 5/5/13, the closed record for R10 contained 51 pages of physician's orders [REDACTED]. This was confirmed by E2, Director of Nursing when the surveyor handed her the 51 pages of orders on 5/5/13 at 2:55 PM. E2 stated that she would have them returned to the correct chart. | 2016-05-01 |
| 3932 | 3932 | MILTON & HATTIE KUTZ HOME | 85043 | 704 RIVER ROAD | WILMINGTON | DE | 19809 | 2012-02-10 | 253 | B | 0 | 1 | HGNF11 | Based on observations and interviews, it was determined that the facility failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Findings include: On 2/6/12, during the environmental tour with E19 (Maintenance) and E21 (Housekeeping) observations revealed that the hand sinks in rooms 101, 601 and 606 were plugged and would not drain properly. The sinks filled up when water was run and took several minutes to drain. On 2/6/12, during an interview with E19 and E21, these findings were confirmed. Observations on 2/9/12 of rooms 601 and 606 revealed that the hand sinks in these rooms continued to be plugged, not draining properly. | 2016-05-01 |
| 4030 | 4030 | COURTLAND MANOR | 85019 | 889 SOUTH LITTLE CREEK ROAD | DOVER | DE | 19901 | 2013-05-23 | 514 | B | 0 | 1 | FU0O11 | Based on record review and interview it was determined that the facility failed to have the correct dates documented on CNA (certified nursing assistant) flow sheets and or treatment administration records for three (R14, R42 and R62) out of 34 sampled residents. Findings include: 1. Review of R14's CNA flow sheet for the month of May 2013 revealed it was dated March 1-31, 2013 instead of May 2013. 2. Review of R42's CNA flow sheet for the month of May 2013 revealed it was dated March 1-31, 2013 instead of May 2013. An interview with E5 (Registered Nurse Assessment Coordinator) on 5/22/13 at 9:45 am confirmed the flow sheets were not dated correctly. E5 continued to state that the facility should have identified these errors during the end of the month paper work review. When the certified nursing assistants documented on them each shift or when the nurses reviewed the flow sheets on the night shift. On 5/22/13 at 10:15 AM E4 (Assistant Director of Nursing) stated that the facility contacted the pharmacy company notifying them of the incorrect dates printed on these forms. E5 continued to state that the pharmacy company will be printing these forms monthly with the correct dates on them. 2. Cross refer F309. Review of R62's Medication Administration Record [REDACTED]. An interview with E13, Registered Nurse on 5/21/13 at approximately 10:30 AM revealed that the MAR forms were printed with specific time frames, thus, the staff would need to correct the dates. Additional review of another MAR for standing orders failed to include the charting period. An interview with E13 on 5/21/13 at approximately 10:30 AM revealed that this MAR indicated [REDACTED]. | 2016-03-01 |
| 4066 | 4066 | SHIPLEY MANOR | 85031 | 2723 SHIPLEY ROAD | WILMINGTON | DE | 19810 | 2011-06-10 | 247 | B | 0 | 1 | 2A9W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to ensure that notice was provided to residents before a room change or when receiving a new roommate for 2 residents (R66 and R107) out of 28 Stage 2 sampled residents. Findings include: Review of the facility's procedure, Roommate Change indicated that social services would notify residents according to state regulation whenever they are to receive a new roommate. Whenever possible the notice should be provided 24 hours in advance of the change. Documentation of the roommate change may be through an interim progress note .or the roommate change notification form. Cross refer F205 1. R107 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. The facility failed to do a bed hold notification with this resident and upon return to the facility R107 was moved to another room. 2. R66 had three roommate changes during 12/2/10 through 3/11/11. R66 was not notified of a new roommate on 12/2/10, 12/10/10 and 3/11/11 prior to receiving a new roommate. Review of R66's social service notes lacked evidence that she had been notified regarding each of these roommate changes. The facility failed to ensure that R107 and R66 received notice before the resident's room or roommate was changed. During an interview on 6/8/11, E1 (Administrator) confirmed these findings. | 2016-02-01 |
| 4074 | 4074 | SHIPLEY MANOR | 85031 | 2723 SHIPLEY ROAD | WILMINGTON | DE | 19810 | 2011-06-10 | 372 | B | 0 | 1 | 2A9W11 | Based on observations of the dumpster area and staff interviews, it was determined that the facility failed to keep the dumpster free of debris to prevent pest harborage. Additionally, a trash can inside the kitchen remained open, uncovered. The lid to this trash can was designed with an opening to maintain refuse covered but stayed in the open position when put on the can. Findings include: 1. Observations of the dumpster area on 6/3/11 at 8:30 AM revealed debris on the floor around the dumpster area such as soiled gloves, papers and plastics. An interview with E5 (Director of Food and Beverage) on 6/3/11 confirmed this finding. Additionally on 6/3/11, observations of the kitchen dishwasher area revealed a large garbage barrel with food refuse was uncovered. The domed lid with an opening in the lid was observed on the floor and not in use. An interview with E6 (kitchen staff) on 6/3/11 revealed that when the lid was placed on the food refuse barrel, it stayed open. This created potential for pest harborage. An interview with E5 on 6/3/11 confirmed this finding. 2. Observations of kitchen water drains on 6/3/11 revealed heavy food debris on the drain located under the Hobart convection oven. The drain was observed with grate not covering the hole on the floor. 3. Observation of the drain located under the refrigerated food table/counter on 6/3/11 revealed heavy food debris inside the drain on the floor. An interview with E6 on 6/3/11 confirmed this finding. | 2016-02-01 |
| 4096 | 4096 | DELAWARE HOSPITAL F/T CHRONICALLY ILL (DHCI) | 85035 | 100 SUNNYSIDE ROAD | SMYRNA | DE | 19977 | 2012-12-07 | 368 | B | 0 | 1 | 7LUC11 | Based on interview and review of facility documents it was determined that the facility failed to ensure that approval from the resident group was obtained, when dinner and breakfast were scheduled 14 ? hours apart. Findings include: Review of the facility's meal service times revealed that tray delivery to each unit had a 14 ? hour period of time from the scheduled dinner meal until the breakfast meal was served the next morning. This 14 ? hour time lapse was consistent on each of the six units. An interview on 12/5/12 at approximately 11:00 AM, E55(dietician) confirmed that more than 14 hours existed between the meal times but that snacks (itemized list with quantities reviewed) were provided daily to each unit and sandwiches were also sent on the snack cart for any resident who was not receiving a prescribed snack. E55 stated she was unaware the facility needed approval from a resident group when there was more than 14 hours between meals. An interview on 12/5/12 at approximately 11:25 AM with E2 (Director of Nursing) revealed that no resident approval of the meal times had been obtained by the facility. This finding was also confirmed with E1 (Administrator) on 12/5/12 at approximately 12:05 PM. E1 did state this matter would be addressed at the next resident council meeting. | 2016-02-01 |
| 4315 | 4315 | PINNACLE REHABILITATION & HEALTH CENTER | 85020 | 3034 SOUTH DUPONT HIGHWAY | SMYRNA | DE | 19977 | 2012-04-25 | 159 | B | 0 | 1 | AQI811 | Based on record review of facility resident fund accounts, corporate accounting methodology and interview and correspondence with corporate accounting staff, it was determined that the facility corporation failed to recognize and resolve a reconciliation discrepancy. Findings include: As of 3/30/2012, a summation of the bank balance of $53,802.78, trial balance of $36,829.56, outstanding checks of $16,863.44, and unawarded interest of $4.79 resulted in a discrepancy of $105.00 in the resident trust fund account. | 2015-10-01 |
| 4316 | 4316 | PINNACLE REHABILITATION & HEALTH CENTER | 85020 | 3034 SOUTH DUPONT HIGHWAY | SMYRNA | DE | 19977 | 2012-04-25 | 160 | B | 0 | 1 | AQI811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of facility policies, it was determined that the facility failed to ensure personal funds were conveyed within 30 days of the death of a resident. Findings include: Review of R40's personal fund account indicated, as of [DATE], there was $322.94 remaining in the account. R40 had expired on [DATE]. Review of R40's medical record revealed that this resident had a responsible party, and the facility had contact information for this person. However, the facility did not convey R40's funds to the responsible party. Review of the facility policy regarding Closing Accounts, revealed the account will be closed and a check shall be issued within 30 days of discharge when a resident is discharged from the facility. Interview on [DATE] with E25 (Business Office Manager) confirmed that R40's personal funds were not conveyed within 30 days after death according to facility policy. | 2015-10-01 |
| 4344 | 4344 | EMILY P. BISSELL HOSPITAL | 85022 | 3000 NEWPORT GAP PIKE | WILMINGTON | DE | 19808 | 2011-07-07 | 372 | B | 0 | 1 | BDGB11 | Based on observations and interviews, it was determined that the facility failed to dispose of garbage and refuse properly. Findings include: On 6/27/11 at 10 AM, observations of an area across from the handwashing sink revealed that two waste receptacles were stored without lids. E22 (Food Service Director) confirmed the finding. | 2015-10-01 |
| 4375 | 4375 | EMILY P. BISSELL HOSPITAL | 85022 | 3000 NEWPORT GAP PIKE | WILMINGTON | DE | 19808 | 2014-08-13 | 159 | B | 0 | 1 | 9W7M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility document review and interviews, it was determined that the facility failed to inform residents of the accessibility to residents' personal funds after hours, that were being managed by the facility. Findings include: The facility provided a policy last revised 4/26/10 that addressed management of residents' funds after business hours whose purpose it listed to establish procedures for providing residents emergency access to funds after regular business hours. The policy's procedures states that the social services department would: - Remind residents to obtain necessary funds during regular business hours. - Provide a combination lock safe to be located in the Nurse Supervisor office. - Provide Nurse Supervisors with information concerning funds available for resident withdraw. - Provide withdraw receipts and a current Personal Needs Account (PNA) Balance report. - Provide Resident Council with this policy. - After checking resident PNA balance report for fund availability, provide resident with emergency funds. The facility admission packet was also reviewed. Under the section entitled Personal Funds and Valuables, patients' are encouraged to deposit money with the Financial Management Department. Within that same paragraph it states that withdrawals from this account can be made at any time during normal working hours. During the Stage I survey process in anonymous interviews on 8/6 and 8/7/14 with 4 out of 30 sampled residents, it was reported that they could not get any money during off hours. An additional interview of a 5th resident was done on 8/12/14 during Stage II and her response was identical. She has been a resident at the facility for several years and was unaware of how to access money off hours. All 5 residents are listed in the MDS as being cognitively intact (able to make own decisions). E8 RN, an [AGE] year employee of the facility that sometimes works at night was interviewed. At times E8 RN also fills in… | 2015-10-01 |
| 4411 | 4411 | MILFORD CENTER | 85010 | 700 MARVEL ROAD | MILFORD | DE | 19963 | 2011-05-31 | 241 | B | 0 | 1 | Q4VU11 | Based on observation and interview it was determined that the facility failed to ensure residents had a dignified dining experience. Findings include: 1. A lunch observation on 5/23/11 on the Homestead unit revealed staff filling disposable plastic cups with fluids. These cups were placed on the dining tables for the residents. The residents were eating lunch and drinking from the disposable plastic cups 2. A lunch observation on 5/26/11 on the Homestead unit revealed staff filling disposable plastic cups with fluids. These cups were placed on the dining tables for the residents. The residents were eating lunch and drinking from the disposable plastic cups. An interview on 5/27/11 at 1:18 PM with E11(social worker), who was serving food on 5/26/11 revealed that the disposable cups were used because no other cups were sent up from the kitchen. She further revealed that disposable cups have been used on the Homestead unit for some time now. An interview on 5/31/11 with the food service director, E6 revealed that she had been on leave and was unaware that the Homestead unit was not receiving regular dining cups. This issue was corrected immediately. | 2015-09-01 |
| 4477 | 4477 | HILLSIDE CENTER | 85013 | 810 SOUTH BROOM STREET | WILMINGTON | DE | 19805 | 2012-06-12 | 356 | B | 1 | 1 | GC6Y11 | Based on observations and staff interview, it was determined the facility failed to post on a daily basis, in a prominent place readily accessible to residents and visitors at the beginning of each shift, the total number and actual hours worked by staff directly responsible for resident care per shift: Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides. The facility also failed to maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater. Findings include: 1. Observations made on 6/1/12 at 10:10 AM of the second floor nursing station revealed Nurse Staffing Information posted that lacked the total hours for the RN's, LPN's and CNA's that had worked. Additionally, the staffing information was observed laying flat on the 2nd floor nursing station table (as the plastic holder was broken) and was not readily accessible to residents unless they specifically asked to see it. In an interview with E4 (ADON) on 6/1/12, she confirmed this finding. Additionally, the staffing information was missing and was not posted in the third floor nursing station on 6/1/12 at 9:15 AM. In an interview with E23 (CNA), she confirmed this finding. 2. On 6/7/12 at 2:30 PM, observations of the third floor and 2nd floor nursing station with a second surveyor revealed Nurse Staffing Information posted that lacked the total hours for the RN's, LPN's and CNA's that had worked. In an interview with E3 (ADON) on 6/7/12 at 2:34 PM, she confirmed this finding. | 2015-08-01 |
| 4510 | 4510 | HARBOR HEALTHCARE & REHAB CTR | 85034 | 301 OCEAN VIEW BLVD | LEWES | DE | 19958 | 2012-04-25 | 174 | B | 1 | 1 | OT9X11 | Based on observation and interview it was determined that the facility failed to ensure that residents on the Henelopen wing had access to a telephone in a private area to prevent calls being overheard. Findings include: 1. During stage I of the survey interview screening questions resident(s) verbalized that there was no privacy when on the telephone. An interview on 4/20/12 with E7 (unit manager) revealed that there was a phone in the dayroom next to the nurses' station that the residents could use. Otherwise, the resident or their family could pay to have a personal phone in their room. It was further revealed that residents in the rehabilitation wing of the unit have phones in their rooms. Observations of the dayroom on 4/20 and 4/23/12 revealed a wall phone right next to the door at the entrance of the room. Residents were noted to be in the room at times to eat and socialize. Staff were noted to be in the room at times to work on the computers and do charting. Interview with E1 (Administrator) on 3/25/12 confirmed that although this room could be a private place if no other residents or staff were using the room it did not provide residents private access to a telephone when other residents and staff were using the room. | 2015-08-01 |
| 4540 | 4540 | DELMAR NURSING & REHABILITATION CENTER | 85041 | 101 E. DELAWARE AVENUE | DELMAR | DE | 19940 | 2011-02-10 | 244 | B | 1 | 1 | SU4511 | Based on facility documentation and interview it was determined that the facility failed to address grievances brought to the facility's attention concerning the food served in the facility. Findings include: Review of the Resident Council Minutes for November 2010 and December 2010 revealed the residents complained that the "hamburgers were tough." The residents made suggestions on foods they would like to have served. Review of the QAA minutes with E33 (QAA nurse) and E1 (administrator) on 2/8/11 at 11:35 AM confirmed the minutes and concerns from the November 2010 and December 2010 Resident Council Meeting were brought to the QAA meetings. Review of the complaints identified by the Resident Council and brought to the QAA committee concerning food with E1 confirmed the resident council as well as other residents in the facility had been complaining about the food. E1 stated that he was working with the dietary manager trying to find ways to address the dietary problems in the facility. E1 also confirmed that the facility failed to put a tool in place to identify and help correct the concerns with food brought to them by the Resident Council. Review of the concerns with dietary concerns with E25 (Dietary Manger) on 2/8/11 at 1:00 PM confirmed she was at the December Resident Council Meeting. She stated she was not aware that the residents were complaining that the hamburger was tough or dry. She stated that one of the surveyors told her about the pork chop being dry and tough and that was the first time she heard of meat being tough. The facility failed to address and act on the food grievances brought to them by Resident Council as well as other residents in the facility. | 2015-08-01 |
| 4541 | 4541 | DELMAR NURSING & REHABILITATION CENTER | 85041 | 101 E. DELAWARE AVENUE | DELMAR | DE | 19940 | 2011-02-10 | 247 | B | 0 | 1 | SU4511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to ensure notice was provided to residents before a room change and when receiving a new roommate. Findings include: Review of the facility's policy for Resident Relocation dated 11/10/10 revealed the policy failed to address the receiving of new roommates. An interview on 2/9/10 with E39 (admissions director) revealed that he occasionally is involved in notifying a resident when they are getting a new roommate. He stated that he does not document his conversations in the residents' records. He believed the social worker documented in the record that a resident was getting a new roommate. An interview on 2/9/10 with E38 (social worker) revealed that she was under the impression that the admissions department handled the new admissions and letting residents know about their new roommates. She stated that if a resident is going from a short term stay to long term placement she will notify them in advance about their room change. She also deals with room changes made due to resident's request. R73 was admitted to room [ROOM NUMBER] on 12/7/10. According to E22 (nurse) on 1/10/11 the resident needed to be moved to a room on the short stay unit to accommodate the placement of a long term resident. R73 was planning on going home. The clinical record failed to have documentation that R73 was notified of the room change. On 1/24/11 R73 told the surveyor that he came back from lunch one day and staff was moving him to another room. | 2015-08-01 |
| 4615 | 4615 | MANORCARE HEALTH SERVICES - WILMINGTON | 85028 | 700 FOULK ROAD | WILMINGTON | DE | 19803 | 2010-03-08 | 323 | B | 0 | 1 | HOYQ11 | Based on observations during the environmental tour with maintenance and environmental staff, it was determined that the facility failed to maintain an environment free from accident hazards as evidenced by an unlocked supply room. Finding includes: Observation on 3/3/10 at 11:00 AM of the first floor New Castle clean utility supply room on a tour with E4 (Maintenance Director) and E5 (Environmental Director) revealed the door to be open and contents accessible to residents. The contents observed were: perineal cleansers, Secura personal cleansers, (2 bottles on counter and approx 10 inside cabinets), Provon shampoo (~10), and body wash (~10). E4 and E5 staff confirmed that the door should be locked. | 2015-07-01 |
| 4718 | 4718 | WILLOWBROOKE COURT AT COUNTRY HOUSE | 85003 | 4830 KENNETT PIKE | WILMINGTON | DE | 19807 | 2011-11-22 | 456 | B | 0 | 1 | JQ8C11 | Based on an observation and staff interviews, it was determined that the facility failed to maintain a kitchen dishwasher in a safe operating condition. Findings include: On 11/14/11 at 8:30 AM, during a tour of the kitchen area with E7 (Dietary Assistant), an observation of the dishwasher in operation at the time revealed a stream of hot water streaming out of the pipe located in the back, top of the dishwasher. The hot water was at a temperature of about 180 degrees Fahrenheit. This caused a potential for injury to employees due to scalding. Wet paper towels were observed around the area of the leaky pipe and the front of the dishwasher unit. In an interview with E7 on 11/14/11, he confirmed this finding. In an interview with E9 (Director of Culinary & Nutrition Services) on 11/14/11 at 11:20 AM, he stated the pipe was repaired. | 2015-05-01 |
| 4730 | 4730 | HARRISON SENIOR LIVING OF GEORGETOWN, LLC | 85029 | 110 W. NORTH STREET | GEORGETOWN | DE | 19947 | 2011-12-14 | 253 | B | 1 | 1 | S49911 | Based on observations made in resident rooms, it was determined that the facility failed to provide maintenance services to provide a homelike environment. Findings include: 1. On 12/06/11, the veneer of the wood work located under the sinks in the following rooms had water damage or wheelchair scuffs and scrapes; 47, 48, 49, 50, 51, 57. Follow-up observation on 12/13/11 confirmed this finding. 2. On 12/13/11, the veneer of the wood work located under the sinks in the following rooms had water damage or wheelchair scuffs and scrapes; 31, 32, 33, 36, 37, 38, 40, 41, 42, 43, 45, and 57. This represented 17 rooms observed out of 56 resident rooms in the facility. | 2015-05-01 |
| 4736 | 4736 | HARRISON SENIOR LIVING OF GEORGETOWN, LLC | 85029 | 110 W. NORTH STREET | GEORGETOWN | DE | 19947 | 2011-12-14 | 431 | B | 1 | 1 | S49911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined that the facility failed to ensure medications were properly stored and labeled. The facility also failed to ensure medications were not accessible to non-licensed staff. Findings include: 1. On [DATE] at 1:04 PM on the Kent Unit the treatment cart contained a tube of hemorrhoid cream that expired in [DATE]. 2. On [DATE] at 3 PM on the Sussex Unit in the medication room a bottle of cough syrup that expired in [DATE] was found. There were also three bottles of opened insulin that were not labled with an open or discard date. 3. The facility's policy for Medication Storage in the Facility stated "The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications." On [DATE], E17 (Medical Records and Storage staff) was observed obtaining the keys to the medication room from E18 (Registered Nurse) and E17 proceeded into the medication room unsupervised for approximately 15 minutes from 10:45 AM to 11 AM. Observations of the Sussex Unit medication room on [DATE] and [DATE] noted medications accessible in cabinets, fridge and containers on the counter top. An interview with the Associate Director of Nursing, E3 on [DATE] confirmed that E17 does go into the medication rooms to stock supplies and she should be supervised by licensed staff when in the medication room. | 2015-05-01 |
| 4756 | 4756 | BRANDYWINE NURSING & REHABILITATION CENTER | 85004 | 505 GREENBANK ROAD | WILMINGTON | DE | 19808 | 2011-12-21 | 162 | B | 1 | 0 | RJ7Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility and hospice staff interviews, it was determined that the facility failed to ensure that one resident (R4) was not imposed a charge against personal funds for multiple doses of a medication ([MEDICATION NAME] for agitation), for which payment was covered by the hospice organization. Facility charged R4 for multiple doses of [MEDICATION NAME] which was covered under the Hospice benefit. Findings include: R4 was admitted to the facility on [DATE] from the hospital as a respite patient of a hospice organization. [DIAGNOSES REDACTED]. R4's record indicated that R4 was discharged to an assisted living facility on 2/25/11. The total stay at the facility was eight days. Record review of Hospice documentation for R4 revealed that [MEDICATION NAME] was a medication that was part of the resident Hospice Care Plan and a covered medication under the hospice plan. On 12/19/11 review of the facility billing documents for medication charges for R4 with E5 (Finance Office staff) revealed, that on 3/20/11 R4 was charged/paid for a total bill $708.48 which included multiple doses of [MEDICATION NAME] 50 mg bill of $158.08. An additional [MEDICATION NAME] pharmacy bill dated 2/20/11 was paid by R4's family member for $81.50. The medication bill was paid by R4's responsible party out-of-pocket on 7/6/11 for all medications indicated by the physician during R4's stay at the facility. Payment for multiple doses of [MEDICATION NAME] was part of the hospice plan of care and hospice was responsible for payment. Review of the Hospice Care Plan (POC) indicated that [MEDICATION NAME] was related to the hospice [DIAGNOSES REDACTED]. as their organization should have paid for this medication. E6 stated that she would contact the hospice social worker to connect with the family about this charge and that they will work on correcting this. In an interview with E5 (Finance Office) and E7 (Admissions director) on 12/21/11, they confirmed that t… | 2015-04-01 |
| 4811 | 4811 | REGAL HEIGHTS HEALTHCARE & REHAB CENTER | 85006 | 6525 LANCASTER PIKE | HOCKESSIN | DE | 19707 | 2011-06-22 | 156 | B | 0 | 1 | ETSZ11 | Based on observations and interview it was determined that the facility failed to post written information on Medicare, Medicaid, and Reporting of Nursing Home Abuse. Findings include: Observations from 6/15/11 through 6/22/11 revealed that the facility failed to have information regarding Medicare, Medicaid, Medicaid fraud control, and Reporting Nursing Home Abuse posted. An interview on 6/15/11 with E1 (Administrator) confirmed these findings. E1 stated that the facility did not have these postings available. | 2015-03-01 |
| 4819 | 4819 | REGAL HEIGHTS HEALTHCARE & REHAB CENTER | 85006 | 6525 LANCASTER PIKE | HOCKESSIN | DE | 19707 | 2011-06-22 | 431 | B | 0 | 1 | ETSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, it was determined that the facility failed to ensure that the drugs and biologicals stored in the medication rooms and medication carts were not expired and that medication refrigerators were free of food products. Findings include: 1.An observation on [DATE] of the C Wing medication cart revealed (1) open 16 ounce bottle of Apap Elixir (Generic Tylenol) which had expired on [DATE]. Immediately after the observation on [DATE], E5 (LPN) confirmed the findings and she removed the medication from the cart. 2.An observation on [DATE] of the E Wing medication cart revealed (1) open bottle of Ranitidine (Acid Reducer) 75mg tablets that expired on [DATE] and (1) open bottle of Aspirin EC (enteric coated) 325mg tablets that expired on [DATE]. E9 (LPN) confirmed these findings immediately after the observation on [DATE] and removed the medication from the cart. 3.An observation on [DATE] of the H Wing medication cart revealed (1) open bottle of Tylenol Extra Strength 500mg tablets that expired on [DATE]. E10 (LPN) confirmed the findings immediately after the observation on [DATE] and removed the medication from the cart. 4. Observation on [DATE] of the B Wing medication refrigerator in the medication storage room revealed there was a plastic container of food and (4) cartons of milk. In an interview with E11(LPN) on [DATE] immediately after the observation, E11 confirmed these findings and stated that she did not know to whom these food items belonged. E11 acknowledged that the food items should not be stored in the same refrigerator as medications and biologicals and she removed the items from the medication refrigerator. | 2015-03-01 |
| 4913 | 4913 | MILTON & HATTIE KUTZ HOME | 85043 | 704 RIVER ROAD | WILMINGTON | DE | 19809 | 2010-09-03 | 156 | B | 0 | 1 | TXFM11 | Based on document review, and resident and staff interviews, the facility failed to periodically review resident's rights during residents' stay at the facility. Findings include: Review of resident council meeting minutes lacked evidence that resident rights were periodically reviewed with the residents. Review of the facility admission packet revealed that resident's rights were included in the packet when residents were admitted to the facility. Interview with R82 on 8/23/10 revealed that the facility did not review resident's rights with the residents during their resident council meetings or any other time during their stay at the facility. Interview with E5 (Admin & Religious Life Director) on 8/30/10 revealed that the facility reviewed the residents rights with them upon admission and if a question was to arise but that these discussions were not documented. | 2015-01-01 |
| 4916 | 4916 | MILTON & HATTIE KUTZ HOME | 85043 | 704 RIVER ROAD | WILMINGTON | DE | 19809 | 2010-09-03 | 465 | B | 0 | 1 | TXFM11 | Based on observations, it was determined that the facility failed to provide a sanitary environment as evidenced from stained/dirty rugs throughout the hallway of the facility, and storage of trash carts and soiled linens on hallways of the facility. Findings include: 1. Observations of the facility hallway rugs on 8/18/10 though 9/3/10 revealed the rugs to be stained or dirty. Facility staff was observed steaming the rugs on 8/19/10 in front of the dining room and the stains or dirt did not come off. 2. Observations of the facility hallways on 8/18/10 and 8/19/10 revealed trash and soiled linen carts stored on the hallways and some of the contents were overflowing. On 8/30/10 on the hallway of the 300 wing, the trash cart had an urine odor. Interview with E13 confirmed this finding. | 2015-01-01 |
| 4927 | 4927 | MILTON & HATTIE KUTZ HOME | 85043 | 704 RIVER ROAD | WILMINGTON | DE | 19809 | 2010-09-03 | 364 | B | 0 | 1 | TXFM11 | Based on observations and interviews, it was determined that the facility failed to serve food that was palatable and at acceptable temperatures. Findings include: During Stage 1 of the survey, residents (who preferred not to be identified) complained of food served too cold. Two resident trays were pulled to test at breakfast time on 8/24/10 at 7:25 AM. Food temperatures were as follows: Tray #1: Strata: 112 degrees Fahrenheit (F); milk: 57 degrees F. Surveyors tasted the food and determined that the hot food was cool and the cold food was warm. Overall, the food was not palatable due to the temperatures. Findings were acknowledged by E15 (Director of Dining Services) that they had problems with their food delivery system in regards to maintaining proper serving temperatures. | 2015-01-01 |
| 4952 | 4952 | HILLSIDE CENTER | 85013 | 810 SOUTH BROOM STREET | WILMINGTON | DE | 19805 | 2011-03-25 | 205 | B | 0 | 1 | 8OJQ11 | Based on facility documentation, record review and staff interviews, it was determined that the facility failed to provide written notice which specified the duration of the bed hold policy to R132 and/or the family member or legal representative. Finding includes: Review of the admissions package, provided to residents and/or family members upon admission to the facility, and R132's signed admission agreement revealed a bed hold (of seven days) when R132 is transferred to the hospital. Interview with E20 (Business Office Manager) on 3/16/11 revealed that R132's letter to the resident or responsible party regarding bed hold prior to the transfer to the hospital was missing. Review of R132's record lacked evidence that a letter was sent or provided to the family or resident. Procedure entitled "Bed Hold Information" under section tiled "Process" revealed that: "the patient and/or legal representative will be contacted by the center designee about a bed hold when the patient is transferred to a hospital for admission...". Section 1.2 stated that "verbal authorization will be accepted and a bed hold Room Reservation Letter will be mailed, if necessary, to obtain written authorization". Procedure stated that "for Medicaid patients follow state requirements for bed holds (including related documentation and notification if applicable)". | 2014-12-01 |
| 4963 | 4963 | HILLSIDE CENTER | 85013 | 810 SOUTH BROOM STREET | WILMINGTON | DE | 19805 | 2011-03-25 | 372 | B | 0 | 1 | 8OJQ11 | Based on observations of the dumpster area during the kitchen tour with E24 (Food Services Director), it was determined that the facility failed to keep one side door and the lid of two dumpsters, which stored garbage and refuse covered to prevent pest harborage. Additionally, three bags of trash and debris were observed on the ground around the dumpster area. Findings include: Observations on 3/8/11 at 9:10 AM of the dumpster area outside the kitchen with E24 (Dietary Services Director) revealed a refuse dumpster (of two) with an uncovered top lid and side door. Additionally, three black bags of refuse (one leaking) and debris around the dumpsters were observed on the ground. This provided access to refuse and harborage for unwanted pests in the facility. E24 confirmed this finding. | 2014-12-01 |
| 4976 | 4976 | HARRISON SENIOR LIVING OF GEORGETOWN, LLC | 85029 | 110 W. NORTH STREET | GEORGETOWN | DE | 19947 | 2011-08-10 | 514 | B | 1 | 0 | 1F0P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that three (3) of thirteen (13) residents reviewed (R11, R1, and R12) had inaccurate information in their clinical records. Findings include: 1. When reviewed by the surveyor on 8/7/11 at 3:55 PM, the clinical record for R11 contained a Plan of treatment for [REDACTED]. E28 took this paper from the surveyor to place in the correct record. 2. R1 left the faciity on [DATE] and was admitted to the hospital. R1 did not return to the facility. A barrier skin cream applied topically to the periarea and [MEDICATION NAME] cream applied to the buttocks were initialed on the Treatment Administration Record (TAR) as administered to R1 on 5/4/11 on the 11 PM to 7 AM shift. R1 was not in the facility at that time. 3. When reviewed on 8/10/11, the closed clinical record for R12 contained two care plan documents for SS2, another former resident of the facility. | 2014-12-01 |
| 4980 | 4980 | DELAWARE HOSPITAL F/T CHRONICALLY ILL (DHCI) | 85035 | 100 SUNNYSIDE ROAD | SMYRNA | DE | 19977 | 2011-08-24 | 253 | B | 1 | 1 | C4D411 | Based on observations throughout the Candee building during the survey, it was determined that the facility failed to maintain resident furnishings in good repair for seven (R129, R28, R194, R55, R175, R106 and R6) out of 47 sampled residents. Findings include: 1. On 8/16/11 at 3:17 PM, the dresser for R129 was missing the front panel to the third drawer from the top. A follow-up observation on 08/23/11 at 11:20 AM revealed identical findings. 2. On 8/16/11 at 2:36 PM, R28 had an out-dated, 1970 ' s style, green vinyl, waiting room chair as her room chair with a semi-patched tear in the seat. This vinyl seat could not be completely cleaned and sanitized due to the tear and repair. A follow-up observation on 08/23/11 at 11:05 AM revealed identical findings. 3. The bed footboard for R194 had scrapes, scuffs, and pieces missing on 8/23/11 at 10:55 AM. 4. On 8/16/11 at 2:52 PM, R55's room had a large green spot on the wall, under the overbed light, where paint was peeling off of the wall and wall damage near the sink was observed. 5. On 8/15/11 at 11:56 AM, R194's room had 2 areas with a large, 8 to 10 inch gouge out of the walls around the bed. 6. On 8/16/11 at 11:52 AM, R175's room was found to have wall scrapes and scratches between the closets next to her bed. 7. On 8/17/11 at 10:10 AM, R106's room had wall scrapes and gouges at the bed headboard area. A follow-up observation on 8/23/11 at 11:03 revealed identical findings. 8. On 8/16/11 at 2:32 PM, R6's room had wall damage about a foot in length under the outlet, under the overbed light in his room. A follow-up observation on 08/23/11 at 11:07 revealed identical findings. | 2014-12-01 |
| 5051 | 5051 | SILVER LAKE CENTER | 85027 | 1080 SILVER LAKE BLVD | DOVER | DE | 19904 | 2011-07-15 | 247 | B | 0 | 1 | VPI411 | Based on interview and review of facility documentation it was determined that the facility failed to ensure two out of 21 residents interviewed in Stage 1 were notified in advance of a new roommate. The facility also failed to have a policy that addressed notifying residents of a new roommate. Findings include: Interview with two anonymous residents in Stage 1 revealed that they had a new roommate but were not aware that the roommate was coming until they arrived in the room. An interview with the Admission Director (E8) on 7/13/11 revealed that it was her practice to tell the residents that they are getting a new roommate when she goes down to set up the room for a new admission. She further stated that if the resident is not in the room she does not go look for them. However, E8 stated she does try to go back to the room and catch the resident before the roommate arrives. This, however, is not documented anywhere. Review of the facility's policy titled "Room Transfer" did not address a resident getting a new roommate. E8 confirmed that the facility policy does not address new roommates. | 2014-11-01 |
| 5065 | 5065 | MANORCARE HEALTH SERVICES - PIKE CREEK | 85033 | 5651 LIMESTONE ROAD | WILMINGTON | DE | 19808 | 2011-01-28 | 253 | B | 0 | 1 | S39R11 | Based on observations on 1/14/11, during the environmental tour with E10 (Maintenance Director), E11 (Environmental Services Supervisor), and E12 (Environmental Services District Manager), it was determined that the facility failed to provide maintenance and housekeeping services necessary to maintain an orderly and sanitary interior. Findings include: 1. Bathroom floor edges were observed encrusted with dirt in resident rooms 137, 152, 159, 217, and 222. The molding at the base of the bathroom wall was nicked in room 159, exposing glue. On 1/14/11, an interview with E11 revealed that there was a gap on the floor where the cove and wall met which exposed the glue. E11 stated they were working on cleaning these floors. Findings were acknowledged by E10 and E11. 2. Observations of emergency call bell cords in resident bathrooms 117, 118, 134, 137, and 205 revealed the cords to be dirty and brown. The cord in resident bathroom 134 was observed dragging on the floor, and the cord was missing in resident bathroom 217. Findings were reviewed with E1 (Administrator) and E2 (Corporate Nurse) on 1/14/11 at 4 PM and with E1, E2 and E10 on 1/25/11 at 1:40 PM. 3. Observations made during the environmental tour on 1/14/11 with E10, E11, and E12 revealed the following equipment in disrepair: a. There was a hole in the wall by the cable plate in resident room 120. The plate was missing. E10 stated that this plate was replaced last week. Review of the maintenance log at the nursing station revealed that this concern was missing from the log; b. The bathroom wall heater end cap in resident room 217 was observed in disrepair; c. Rust was observed in the hand sink in bathroom 118; d. The closet door panel in room 101B was observed in disrepair; e. A lamp heater in one shower stall in the Arcadia common shower room was in disrepair (noisy); f. The wall switches for three shower stall lamp heaters on the Linden unit common shower room were observed to be loose and two plates were sideways rather than upright on the wall which created… | 2014-11-01 |
| 5092 | 5092 | EMILY P. BISSELL HOSPITAL | 85022 | 3000 NEWPORT GAP PIKE | WILMINGTON | DE | 19808 | 2009-09-23 | 253 | B | 0 | 1 | 3U6C11 | Based on observations and staff interview on 9/9/09, it was determined that the facility failed to provide maintenance services necessary to maintain an orderly interior. Findings include: Observations at 8:45 AM of the dry food storage room with E6, Food Service Director, revealed a wall with peeling paint. Additionally, the hallway ceiling paint near the dry food storage room was peeling. An interview with the director confirmed these concerns. | 2014-10-01 |
| 5183 | 5183 | MILFORD CENTER | 85010 | 700 MARVEL ROAD | MILFORD | DE | 19963 | 2009-09-09 | 241 | B | 0 | 1 | GYID11 | Based on observation it was determined that the facility failed to ensure that all residents had a dignified dining experience. Findings include: Lunch observation on 9/1/09 between 12:15 PM and 12:45 PM revealed the following; 1. One table of residents were served their lunch on cafeteria trays while three other tables of residents were served their meals restaurant style. 2. Aide, E4 was observed feeding SSR2 standing up. 3. Meals came out of the kitchen in an manner that caused residents at the same table to watch other residents eat their lunch before fell ow residents received their meal. | 2014-08-01 |
| 5185 | 5185 | MILFORD CENTER | 85010 | 700 MARVEL ROAD | MILFORD | DE | 19963 | 2009-09-09 | 280 | B | 1 | 1 | GYID11 | Based on record review, interview and review it was determined that the facility failed to have a system to notify and invite one cognitively intact resident (R15) out of 24 sampled residents of their care plan meetings. In addition, the facility failed to obtain permission from R15 prior to inviting a family member. Findings include: Review of R15's admission and most recent quarterly Minimum Data Set (MDS) assessments dated 11/24/08 and 8/14/09 respectively indicated that the resident was cognitively intact and independent in daily decision making. Review of R15 ' s records revealed care plan meetings were held on 3/3/09, 6/8/09, and 9/2/09 and that both the resident and the primary contact, R15 ' s daughter were notified of the meetings. An interview with R15 on 9/3/09 at 3:45 PM revealed that she does not recall being notified or invited to an Interdisciplinary Care Plan (ICP) . Review of the facility's Care Plan and Assessment policy indicated that the facility will notify the resident and primary contact prior to the ICP meetings, encourage them to attend, and solicit their input. Additionally, the policy indicated that the primary contact will be invited with the customer's permission. Although facility records documented that both the resident and the primary contact were invited to the above ICP meetings, this documentation conflicted with what was actually completed. Additionally, the records lacked evidence that the facility obtained the resident's permission prior to inviting the primary contact to the ICP meetings. An interview with the Director of Social Services, E10 on 9/8/09 at 11 AM revealed that that facility's process was to invite the primary contact of each resident to the ICP meeting, however, resident permission was not obtained prior to the invitation. Additionally, the system failed to notify and invite a resident, who was competent to participate in the ICP meetings. Findings reviewed with the Administrator, E1 on 9/9/09 at 8:30 AM. | 2014-08-01 |
| 5187 | 5187 | MILFORD CENTER | 85010 | 700 MARVEL ROAD | MILFORD | DE | 19963 | 2009-09-09 | 161 | B | 0 | 1 | GYID11 | Based on review of the residents' funds account and surety bond for that account, it was determined that the facility failed to assure the security of all personal funds of residents deposited with the facility. Findings include: 1. Review of the residents' funds account and surety bond on 09/07/09 revealed that the surety bond was insufficient to cover the maximum balance of the account. A surety bond rider from 2007 had increased the covered amount to $80,000. The maximum balance on 07/01/09 was $93,466.92. An updated rider was put in place on 09/09/09 to the sum of $100,000. | 2014-08-01 |
| 5219 | 5219 | BRANDYWINE NURSING & REHABILITATION CENTER | 85004 | 505 GREENBANK ROAD | WILMINGTON | DE | 19808 | 2010-10-01 | 253 | B | 0 | 1 | CHOX11 | Based on observations throughout the survey and the environmental tour with the facility maintenance director on 9/27/10, it was determined that the facility failed to provide maintenance and housekeeping services necessary to maintain an orderly and sanitary interior. Findings include: 1. Unpainted, dirty or scratched walls were observed in resident rooms: F3, F6, F9, F11, F14, G2, G4, G8, and E14. 2. Odors were detected in resident rooms C6, D11, D12 and D14. Additionally, the E-Wing soiled utility room had odors and the exhaust vent was not working. 3. The caulking around the base of the toilets in resident bathrooms C6, C10, D6, D8, D11, D12, F9, F11, E15, F6, G8, and G16 were observed brown, stained and in disrepair. 4. The bathroom floor edges were observed encrusted with dirt in resident room F11 and other rooms in the F-Wing. 5. Dirt/debris was observed on over the bed tables in rooms B12B and F11A. 6. Toilets were observed cracked or in disrepair in resident rooms F6, G16 and the F-Wing central bath. On 9/27/10, an interview with E19 (Environmental Director) confirmed these findings. | 2014-07-01 |
| 5222 | 5222 | BRANDYWINE NURSING & REHABILITATION CENTER | 85004 | 505 GREENBANK ROAD | WILMINGTON | DE | 19808 | 2010-10-01 | 241 | B | 0 | 1 | CHOX11 | Based on observations and interviews it was determined that the facility failed to ensure that many residents were treated in a dignified manner. Residents were served milk from cartons during meals without being provided with beverage glasses. Additionally, other beverages were served in disposable, plastic cups. Findings include: During mid-day meal dining observations on 9/22/10, residents in the Elsmere and Greenbank dining rooms were served milk directly from individual cartons and were not provided glasses or straws from which to drink. Additionally, residents were served other beverages from disposable, plastic cups. Meal observations throughout the survey period revealed that residents in the Elsmere dining room were served beverages in disposable, plastic cups. During an interview with E13 (Food Service Director) on 9/30/10, he stated that there were not enough non-disposable glasses for all of the residents and that they had just ordered more. | 2014-07-01 |
| 5259 | 5259 | ST. FRANCIS CARE/BRACKENVILLE | 85042 | 100 ST. CLAIRE DRIVE | HOCKESSIN | DE | 19707 | 2011-11-07 | 156 | B | 0 | 1 | HSC611 | Based on observations and staff interviews, it was determined that although the facility had the state agency survey results in the lobby, the facility failed to display a sign indicating where the survey results were located. Additionally, the Medicare and Medicaid phone numbers were not posted. Findings include: Observation of the facility lobby, hallways and common areas on 11/3/11 revealed the above listed information could not be found within the building. In an interview with E1 (Administrator) on 11/3/11, he confirmed this finding. At a later time on 11/3/11, E1 indicated that the sign for the agency survey result reports and the Medicare/Medicaid numbers were posted within the facility and were readily accessible to all residents and visitors. | 2014-07-01 |
| 5275 | 5275 | CADIA REHABILITATION RENAISSANCE | 85052 | 26002 JOHN J WILLIAMS HIGHWAY | MILLSBORO | DE | 19966 | 2010-08-12 | 247 | B | 0 | 1 | 7PO411 | Based on review of the facility's policy and procedures and interview it was determined that the facility failed to consistently notify residents of the admission of new roommates. Findings include: Review of the facility's policy and procedure "Admission Policy" revealed "4. Each resident will be notified by a staff member regarding the impeding arrival of a roommate." Interview with R276 on 8/4/10 at 1:52 PM revealed she had four roommates in the last 4 weeks. R276 stated when the bed is empty she knows she will be getting a new roommate. On 8/9/10 at 11:35 AM interview with E8 (unit secretary) revealed the staff do not always know when they are getting a new resident until about an hour before they show up. On 8/9/10 at 11:40 AM interview with E9 (LPN) revealed the staff are suppose to let residents know when they are getting a new roommate. E9 continued to state that sometimes the staff just introduces the residents to each other when the new roommate arrives. On 8/9/10 at 11:45 AM interview with E10 (RN Unit Manger) revealed if there is a room change she notifies the roommate. Sometimes she does not know of an admission until the resident shows up. She confirmed that the staff do not always let the residents know that they are getting a new roommate until the new resident arrives. | 2014-07-01 |
| 5280 | 5280 | CADIA REHABILITATION RENAISSANCE | 85052 | 26002 JOHN J WILLIAMS HIGHWAY | MILLSBORO | DE | 19966 | 2010-08-12 | 253 | B | 0 | 1 | 7PO411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined that the facility failed to provide housekeeping services in one room to maintain a clean and odor free environment. Findings include: Observations in room 226a on ,[DATE] (afternoon) and [DATE] (throughout day) revealed a smell of urine. There were three open empty plastic urinals hanging on a-beds side of the room. During one observation the resident was eating his lunch and three flies were around the resident and his bed. There was a smell of urine. On [DATE] at 9:25 AM the room smelled of urine and there were two empty urinals hanging in room. An interview on [DATE] at 12:24 PM with E12 (housekeeping director) confirmed the smell of urine and revealed that both gentleman in the room had issues that resulted in urine being spilled in room. He further stated that the resident in 226b had expired this weekend and a thorough cleaning would be done. Observation on [DATE] at 11:20 AM revealed a smell of urine. An interview with nurse E4 (nurse) on [DATE] at 1 PM revealed that R34 wants to use his urinal independently but often spills some of the urine on the floor, the fall mats, the bed and himself then the staff have to go behind him to clean up. | 2014-07-01 |
| 5291 | 5291 | FIVE STAR FOULK MANOR NORTH LLC | 08A011 | 1212 FOULK ROAD | WILMINGTON | DE | 19803 | 2009-06-12 | 497 | B | 0 | 1 | VHBN11 | Based on a review of facility documentation and staff interview, it was determined that the facility failed to insure that two (2) (E14 and E15) of three (3) sampled nursing assistants received the mandatory annual performance review. Findings include: 1. E14 was hired 10/5/01. The date of the latest evaluation in the personnel file was 10/22/07. 2. E15 was hired 4/5/03. Review of the performance evaluation in the personnel file revealed the absence of any signatures. An interview on 6/10/09 with E17 (Human Resources Specialist) confirmed these findings. | 2014-07-01 |
| 5320 | 5320 | CADIA REHABILITATION BROADMEADOW | 85050 | 500 SOUTH BROAD STREET | MIDDLETOWN | DE | 19709 | 2011-01-18 | 247 | B | 1 | 1 | YDW211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to notify one out of 33 sampled residents (R102) about a room mate change. Staff interview revealed that notification of a room mate admission was not normally done on the short-term, rehabilitation unit. Findings include: 1. R102, who was admitted to the facility on [DATE], indicated in an interview on [DATE], that she never received notification when a room mate was admitted to her room. R203 was admitted to the facility, and the room of R102, on [DATE]. On [DATE], at 10:15 AM, interview with E11, Social Services Director, indicated that admission notifications were not typically given out on the short-term, rehabilitation unit (Everett). The population is in and out so much, the facility didn't view it as necessary, unless the resident was being transferred to the long-term care unit. On [DATE], at 10:30 AM, interview with E7, Everett unit manager, indicated that he did recall working on the day of R203's admission but could not recall if R102 was informed of the admission prior to it happening. He stated that the standard practice in the facility was to inform the resident that a room mate was coming when the room was readied for their arrival. No notations in nurse's notes, admission notes, activities notes, nor social services notes were written regarding informing R102 that a room mate was arriving on [DATE]. | 2014-06-01 |
| 5329 | 5329 | CADIA REHABILITATION BROADMEADOW | 85050 | 500 SOUTH BROAD STREET | MIDDLETOWN | DE | 19709 | 2011-01-18 | 514 | B | 1 | 1 | YDW211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined for 3 (R208, R205 and R206 ) out of 33 sampled resident the facility failed to maintain clinical records that were complete and accurately documented. Findings include: 1. a.On 6/21/10 R208's MAR documented a new order for [MEDICATION NAME] 15 cc po q 4 hr prn for mild diarrhea x 24 hours. The [MEDICATION NAME] was administered on 6/21/10 at 0915, the nurse failed to document on the back of the MAR the reason for its use and the results of the medication as required for prn (as needed) medications. b. A nurse's note dated 6/21/10 and timed 10:05 PM indicated that R208 had "x2 loose stools this shift, [MEDICATION NAME] given with + results thus far patient also c/o burning on peri area. Noted with redness like rash and excoriation, on MD book to evaluate perineal care provided thoroughly and protective cream applied, pt stated it felt much better". The nurse failed to sign the MAR for the administration of this medication and failed to document the reason and results on the back of the MAR. c. On 6/21, 6/22 and 6/23/10 the nurses' initials for Senna 2 tabs daily were circled on MAR indicating it was held but there was no documentation on the back of the MAR as to why. d. On 6/21 12 PM dose, 6/22 12 PM dose, and 6/23 12 PM and 8 PM dose the nurses' initials were circled for [MEDICATION NAME] 100 mg indicating that it was held. There were no notes on back of MAR as to why. 2. a. Review of R205'S MAR (medication administration record) on 1/12/11 revealed medications were not signed off as being administered to R205 on the 3-11 shift for 1/11/11. On 1/12/11 at 11:30 AM review of R205's MAR and medication counts with E7 (RN unit manager) confirmed E18 (RN) failed to document the administration of medications to R205 on 1/11/11. b. R205 had a physician order [REDACTED]." A physician's order for "Ambien CR 6.25 mg po q hs prn" was dated and signed on 12/30/10. On 12/30/10 and signed 1/3/11 by the… | 2014-06-01 |
| 5334 | 5334 | DELAWARE VETERANS HOME | 85051 | 100 DELAWARE VETERAN'S DRIVE | MILFORD | DE | 19963 | 2011-02-03 | 465 | B | 1 | 0 | 8NOJ11 | Based on surveyor observations, it was determined that the facility failed to provide a sanitary environment in the common sitting areas of the three residential units (Gold unit, Red unit, and Green unit). Findings include: 1. On 1/22/11 at 5:10 PM, 1/23/11 at 10:45 AM and 1/29/11 at 9:55 AM, the following observations were made in the common sitting room (where the television was located) of the Gold unit: Four dark blue vinyl recliner chairs along the wall had dried, white liquid drip marks visible down the front of the chairs. The red vinyl loveseat had visible dried residue on the front of the loveseat below the left cushion. 2. On 1/22/11 at 5:20 PM, 1/23/11 at 10:50 AM, and 1/29/11 at 10:15 AM, the following observations were made in the common sitting room (where the television was located) of the Red unit: The red vinyl couch in the back of the room had visible, dried residue on the lower front. The green fabric covered seat surface of a chair had visible brown and white stains. 3. On 1/22/11 at 5:30 PM, 1/23/11 at 12:25 PM, and 1/29/11 at 12:07 PM, the following observations were made in the common sitting area (where the television was located) of the Green unit: The green fabric covered seat surface of a chair had visible white stains. A second chair had visible gray stains on the green fabric covered seat surface. | 2014-06-01 |
| 5335 | 5335 | DELAWARE VETERANS HOME | 85051 | 100 DELAWARE VETERAN'S DRIVE | MILFORD | DE | 19963 | 2013-11-26 | 372 | B | 0 | 1 | 87PG12 | Based on observation and interview, it was determined that the facility failed to dispose of garbage and refuse properly. Findings include: 1. Observation of the canteen area on 11/22/13 at approximately 11:15 AM revealed a garbage barrel that had a lid with an opening in the center. A fly was observed coming out of the garbage barrel into the room. In an interview with E5 (Dietary Staff) on 11/2/2/13 at approximately 11:15 AM, she confirmed this finding. 2. On 11/22/13 at approximately 11:35 AM, a garbage barrel containing food refuse was observed uncovered in the Gold unit lounge/activity room. Additionally, a banana peel, which needed to be discarded, was observed in the room on a table. 3. On 11/22/13 at approximately 12:00 PM and on 11/25/13 at approximately 10:00 AM and 11:30 AM, two garbage barrels containing food refuse were observed uncovered in the Main dining room. 4. On 11/25/13 at approximately 10:20 AM, a cart with an uncovered bin filled with food refuse in dirty water was observed in the dining room. One table was observed with dirty breakfast plates/ food refuse. There were no dietary staff in the dining room cleaning up. In an interview with E7 (Housekeeping Supervisor) on 11/25/13 at approximately 10:20 AM, he confirmed this finding. In an interview with E8 (Dietary Supervisor) on 11/25/13 at approximately 10:22 AM, she stated that all the dietary staff went to their regular early lunch and left the uncovered food refuse until they got back to clean it. | 2014-06-01 |
| 5336 | 5336 | PARKVIEW NURSING | 85002 | 2801 W. 6TH STREET | WILMINGTON | DE | 19805 | 2009-12-18 | 253 | B | 3PSC11 | Based on observations during the environmental tour with maintenance and housekeeping staff (E4 and E5) on 12/10/09 at 10:35 AM, it was determined that the facility failed to provide maintenance and housekeeping services necessary to maintain an orderly interior. Findings include: On 12/10/09, the following observations were made in the facility: - Unpainted plaster was observed on the walls of resident rooms #102 and #407. - Nine dirty ceiling tiles were observed in different areas such as resident rooms#:102,109, 406 (2), 407(2), the beauty parlor (2), and in the hallway outside room 407. Additionally, streaks of yellow paint in the white ceiling of room 101 was observed. - Missing closet doors were observed in resident room #317 and #320A. - A dirty floor mat was observed in resident room 205B on 12/7/09 and 12/10/09. The floor mat of resident room 406 was observed dusty. - The window blind of resident room #310 was in disrepair. -Observation of the bathroom in resident room #406 revealed a wall tile in disrepair. - Observation of the swinging door from the 400 unit to the main dining room revealed heavy black marks on the bottom part of the door. Housekeeping staff interview (E5) on 12/10/09 at 11:30 AM confirmed these findings. | 2014-04-01 | ||
| 5337 | 5337 | PARKVIEW NURSING | 85002 | 2801 W. 6TH STREET | WILMINGTON | DE | 19805 | 2009-12-18 | 371 | B | 3PSC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and procedure review, it was determined the facility failed to protect food during preparation and distribution. Findings include: 1. On 12/7/09 at 8:30 AM, observation of a bucket containing a [MEDICATION NAME] solution used to clean and sanitize kitchen surfaces was sitting by the kitchen steam table. Surveyor requested the solution be tested to determine the amount of sanitizer in the solution. Interview with dietary staff (E6) revealed that they had no way to test the solution. On 12/10/09, interview with the dietary staff E6 revealed that they are supposed to be using the same sanitizing solution found in the three compartment sink to sanitize the surfaces of equipment in the kitchen. Procedure review on 12/10/09 revealed that all surfaces in the kitchen were to be sanitized. Follow-up interview with the chemical manufacturer's representative on 12/29/09 revealed that this chemical is inappropriate for use in sanitizing contact food surfaces, and was recommended for floor cleaning. 2. On 12/7/09 at 10:05 AM, a dietary staff was observed in the kitchen with the hair covered half way (pony tail only). On 12/17/09 during dinner time, a dietary staff (E8) was observed working at the steam table without a hair restraint. | 2014-04-01 | ||
| 5357 | 5357 | REGAL HEIGHTS HEALTHCARE & REHAB CENTER | 85006 | 6525 LANCASTER PIKE | HOCKESSIN | DE | 19707 | 2009-08-14 | 174 | B | MMBL11 | Based on observations, staff interviews and an individual resident interview, it was determined that the facility failed to provide residents phone access in a private area where calls could be made without being overheard. Findings include: On 8/14/09 at 10:10 AM, SSR31 was observed asking staff to use a phone. E22 (CNA), brought the resident to the Hammond wing nurse's station to use the phone. While E22 was helping SSR31 dial the phone, the resident was interrupted three times by incoming calls before he was able to place the call. When asked if there was a private place for a resident to make a call, E22 stated that the nurse's station was the only place that she knew for a resident to use the phone. E23 (Unit Clerk) agreed that the nurse's station was not a private place to make a phone call. In an interview with E12 (nurse), she stated that residents sometimes used phones in staff offices and that there was also a phone in the B-wing dining room that was available for resident use. Interview with Human Resource staff, E24 and E18 revealed that they were unsure of where residents could make private phone calls besides staff offices, but they would try to find out. During an interview with E14 (nurse) on 8/14/09, she stated that residents can make phone calls using the phone in the B-wing dining room or in the unit manager's office. Interview with SSR32, who was alert and oriented on 8/14/09, revealed that the only places that he knew that residents could make phone calls was the B-wing dining room or at nurses stations. During an interview with E25 ( Corporate Nurse) and E26 (General Manager) on 8/14/09, they revealed a cell phone that was kept in the administrator's office which was for residents' use. They confirmed that facility staff were unaware of the existence of the cell phone and stated that they would make them aware of its availability to the residents. | 2014-04-01 |
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CREATE TABLE [cms_DE] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );