Courtland Manor

F-F690

Review of Resident R63's clinical record revealed:

9/23/24 - Resident R63 was admitted to the facility.

9/23/24 - A care plan (last updated 1/6/25) was initiated for Resident R63 and documented Resident R63 had a self care defecit related to limited mobility with interventions including Resident R63 was completely dependent on staff for toileting use and to encourage Resident R63 to participate to the fullest extent possible with care.

9/27/24 - An admission MDS assessment documented Resident R63 was dependent on staff for toileting. The MDS also documented Resident R63 was always incontinent of bowel and bladder and was not on a toileting program.

12/27/24 - A quaterly MDS assessment documented Resident R63 was dependent on staff for toileting. The MDS also documented Resident R63 was always incontinent of bowel and frequently incontinent bladder and was not on a toileting program.

The facility failed to develop and implement a comprehensive resident centered care plan related to Resident R63's incontinence.

2/19/25 1:41 PM - Findings were reviewed during the exit conference with E1(NHA) and E2 (DON).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 26 085019 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085019 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Terrace Rehabilitation and Health Center 889 South Little Creek Road Dover, DE 19901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Level of Harm - Minimal harm or potential for actual harm 46988

Residents Affected - Few Based on record review and interview, it was determined for two (Resident R22 and Resident R63) out of eighteen residents in

the investigative sample the facility failed to review and revise the care plan. Findings include:

1. Review of Resident R22's clinical record revealed:

12/14/18 - Resident R22 was admitted to the facility.

12/14/18 - A care plan documented that Resident R22 had a self care deficit related to impaired mobility and cognitive defect with the following interventions: provide total assist with personal hygiene and dressing, provide a bed bath per RP (responsible party) and risk for falls in shower chair due to severe chorea.

2/19/25 10:30 AM - An interview with E3 (ADON) confirmed that Resident R22 was unsafe to use shower chair or stretcher related to falls and that care plan was not updated to accurately reflect Resident R22's current plan of care.

2. Review of Resident R63's clinical record revealed:

9/23/24 - Resident R63 was admitted to the facility.

9/25/24 - A care plan for Resident R63 was initiated for pain related to chronic pain with the following interventions: administer analgesia per orders, monitor and document side effects from pain medication, monitor/record/report to nurse any signs and symptoms of pain to the nurse, and notify the physician if interventions are unsuccessful or if current complaint is a significant change from resident's experience of pain.

2/14/25 12:31 PM - An interview with E2 (DON) and E19 (Corporate) confirmed that Resident R63's care plan lacked

an acceptable level of pain and updated interventions related to non-pharmacological interventions.

2/19/25 1:41 PM - Findings were reviewed during the exit conference with E1(NHA) and E2 (DON).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 26 085019 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085019 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Terrace Rehabilitation and Health Center 889 South Little Creek Road Dover, DE 19901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or 32810 potential for actual harm Based on observation, interview and record review, it was determined that for three (Resident R19, Resident R22 and Resident R55) out Residents Affected - Few of five residents reviewed for ADL's, the facility failed to ensure ADL care was provided to dependent residents. Findings include:

1. Review of Resident R55's clinical record revealed:

1/2/25 - Resident R55 was admitted to the facility with multiple diagnoses including legal blindness.

1/3/25 - A baseline care plan documented that Resident R55 had visual impairment and needed substantial maximum assistance with hygiene.

1/9/25 - An admission MDS assessment documented that Resident R55's vision was severely impaired, and that the resident required partial moderate assistance to complete hygiene related ADL's such as shaving.

2/11/25 9:08 AM - During an interview Resident R55 stated, I have a brand new razor and they have used it once. I can't see and need help to shave. Resident R55 was observed with significant unkempt facial hair that he confirmed was not his preference.

2/14/25 10:48 AM - Resident R55 was observed with unkempt facial hair.

2/14/25 1:11 PM - The surveyor accompanied E11 (CNA) to Resident R55's room where Resident R55 remained with unkempt facial hair. E11 confirmed that that she was aware of Resident R55's visual impairment and did not offer to assist Resident R55 with shaving/hygiene because This is a rehab floor so I assume they can all do that themselves.

February 2025 - Review of the CNA task completion documented that hygiene, which includes shaving, was documented as completed and was inconsistent with observation of Resident R55's unkempt facial hair.

46988

2. Review of Resident R19's clinical record revealed:

3/7/18 - Resident R19 was admitted to the facility.

3/7/18 - A care plan documented that Resident R19 had a self care defect for related to impaired mobility and cognitive defect with the following interventions: provide total assist with with personal hygiene and dressing, provide tub bath/shower two times a week, and provide tub bath/ shower with total dependence.

12/27/24 - A quarterly assessment documented that Resident R19 was dependent with one staff member for ADL's including showering and bathing.

1/2025 - A review of the January CNA documentation record revealed that Resident R19 was receiving two showers a week on Sunday and Thursday.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 26 085019 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085019 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Terrace Rehabilitation and Health Center 889 South Little Creek Road Dover, DE 19901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 2/2025 - A review of the February CNA documentation record revealed that Resident R19 was receiving two showers

a week on Sunday and Thursday. Level of Harm - Minimal harm or potential for actual harm 2/13/25 11:34 AM - An observation of Resident R19 with uncombed, unmanaged, greasy hair.

Residents Affected - Few 2/14/25 1:50 PM - An observation of Resident R19 with uncombed, unmanaged, greasy hair.

2/17/25 9:35 AM - An observation of Resident R19 with uncombed, unmanaged, greasy hair.

2/18/25 9:54 AM - An observation of Resident R19 with uncombed, unmanaged, greasy hair.

2/19/25 9:30 AM - An observation of Resident R19 with uncombed, unmanaged, greasy hair.

2/19/25 9:50 AM - An interview with E28 (CNA) confirmed that Resident R19's shower's were signed off and confirmed

the Resident R19's hair did not appear clean. E28 stated that typically the floor has limited staff and it is difficult to complete twelve residents per CNA, especially on shower days. E28 stated a CNA can be scheduled to come in and assist with showers but they have not been in since previous week.

2/19/25 10:30 AM - An interview with E3 (ADON) confirmed that a CNA responsible for showers was not present on unit today and will review acuity for the unit to see if they can get more staff to assist the unit.

The facility failed to assist a dependent resident with ADL care.

3. Review of Resident R22's clinical record revealed:

12/14/18 - Resident R22 was admitted to the facility.

12/14/18 - A care plan documented that Resident R22 had a self care defect for related to impaired mobility and cognitive defect with the following interventions: provide total assist with with personal hygiene and dressing, provide a bed bath per RP (responsible party) and risk for falls in shower chair due to severe chorea.

1/3/25 - A CNA task for Resident R19 was revised for bed baths on Tuesday's 3 to 11 and Friday's 7 to 3 and bed bath for all other days unless specified.

2/13/25 11:44 AM - An observation of Resident R22 with uncombed, unmanaged, greasy hair.

2/14/25 1:40 PM - An observation of Resident R22 with uncombed, unmanaged, greasy hair.

2/17/25 9:55 AM - An observation of Resident R22 with uncombed, unmanaged, greasy hair.

2/18/25 10:07 AM - An observation of Resident R22 with uncombed, unmanaged, greasy hair.

2/19/25 9:30 AM - An observation of Resident R22 with uncombed, unmanaged, greasy hair.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 26 085019 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085019 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Terrace Rehabilitation and Health Center 889 South Little Creek Road Dover, DE 19901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 2/19/25 9:50 AM - An interview with E28 (CNA) confirmed that Resident R22's bath's were signed off and confirmed

the Resident R22's hair did not appear clean. E28 stated that typically the floor has limited staff and it is difficult to Level of Harm - Minimal harm or complete twelve residents per CNA, especially on shower days. E28 stated a CNA can be scheduled to potential for actual harm come in and assist with showers but they have not been in since previous week.

Residents Affected - Few 2/19/25 10:30 AM - An interview with E3 (ADON) confirmed that a CNA responsible for showers was not present on unit today and will review acuity for the unit to see if they can get more staff to assist the unit.

The facility failed to assist a dependent resident with ADL care.

2/19/25 1:41 PM - Findings were reviewed during the exit conference with E1(NHA), and E2 (DON).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 26 085019 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085019 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Terrace Rehabilitation and Health Center 889 South Little Creek Road Dover, DE 19901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or 46988 potential for actual harm Based on interview and record review it was determined that for two (Resident R43 and Resident R63) out of two residents Residents Affected - Few reviewed for general care and services, the facility failed to ensure treatment and care in accordance with professional standards of practice and physician orders. Findings include:

1. Review of Resident R43's clinical record revealed:

4/8/24 - Resident R43 was admitted to the facility with diagnoses including but not limited to constipation.

12/30/24 - A quarterly MDS assessment documented that Resident R43 has a diagnosis of constipation unspecified.

1/2/25 - A review of physician's orders revealed the following orders:

-Milk of Magnesia (MOM) give 30 mL every seventy two hours as needed for constipation if no bowel movement (BM) after three days.

-Bisacodyl suppository 10 mg insert one suppository rectally as needed for constipation daily if no results from MOM.

-Fleet enema insert one dose rectally every twenty four hours as needed if no BM in three days.

1/21/25 to 2/10/25 - Review of the CNA documentation sheet revealed that the facility failed to ensure that physician's orders were implemented when Resident R43 failed to have bowel activity for nine (9) shifts on the following dates:

- 2/10/25 ending on 7 AM to 3 PM shift - total of 12 shifts.

2/18/25 12:40 PM - An interview with E16 (LPN) revealed that the bowel protocol is initiated by the 7 AM to 3 PM shift after review of the facilities BM report and the supervisor will notify nurses who is on the list to have protocol initiated. 7 AM to 3 PM will document medication in the electronic medical record (EMR) and verbally notify the next shift regarding results of protocol. E16 confirmed that Resident R43 had 12 shifts with no BM and protocol was initiated.

2. Review of Resident R63's clinical record:

9/23/24 - Resident R63 was admitted to the facility with the following diagnoses but not limited to venous insufficiency and local infection of the skin and subcutaneous tissue.

12/17/24 - A physician's order documented acetic acid irrigation solution use one application every day shift for open areas to Resident R63's left lower leg: cleanse left lower leg with acetic acid and apply bacitracin and abdominal pad daily and as needed. Order was discontinued 1/20/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 26 085019 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085019 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Terrace Rehabilitation and Health Center 889 South Little Creek Road Dover, DE 19901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 1/17/25 - A physician's order documented to Resident R63's left leg dressing apply bacitracin (antibiotic ointment) then non-adherent dressing, wrap with ACE bandage. Level of Harm - Minimal harm or potential for actual harm 2/11/25 - A physician's order documented to cleanse Resident R63's left leg with soap and water then apply dermaseptin infused kling and wrap legs daily and as needed. Residents Affected - Few 2/13/25 11:25 AM - An observation of wound care to Resident R63's lower extremities revealed that E20 (LPN) administered acetic acid irrigation solution to Resident R63's lower left leg and applied bacitracin ointment to open areas post irrigation solution.

2/13/25 2:37 PM - An interview with E20 confirmed that the current physician's order in the system was not

the same as the treatment administered at 11:25 AM. E20 stated she was given a verbal order by E9 (Physician) this morning and to change the treatment. Facility documentation did not reflect this change in treatment orders.

2/14/25 12:31 PM - An interview with E9 confirmed that the treatment order in the EMR was not the current order for Resident R63's current plan of care.

The facility failed to follow a physician's order.

2/19/25 1:41 PM - Findings were reviewed during the exit conference with E1(NHA), and E2 (DON).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 26 085019 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085019 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Terrace Rehabilitation and Health Center 889 South Little Creek Road Dover, DE 19901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Level of Harm - Minimal harm or potential for actual harm 46988

Residents Affected - Few Based on observation and interview, it was determined that for one (Resident R31) out of two residents reviewed for positioning and mobility, the facility failed to apply an ordered splint device. Findings include:

Review of Resident R31's clinical record revealed:

2/13/19 - Resident R31 was admitted to the facility with diagonoses to including hemipleglia and hemiparesis following

a cerebral vascular accident.

2/13/19 - A care plan was initiated for Resident R31 documented actual contractures related to decreased mobility with the following interventions: left and right hand/wrist orthotic on each shift, maintain joints and body in a neutral body position at all times, and passive range of motion as tolerated.

6/26/24 - A physician's order for Resident R31 documented apply right hand/wrist orthortic on every shift and remove for range of motion (ROM), hygiene, and routine skin checks every two hours.

12/12/24 - A physician's order for Resident R31 documented apply left hand soft resting hand splint to be on in morning and remove in evening.

1/7/25 - A quarterly MDS assessment documented that Resident R31 had impairments bilaterally to upper extremities and dependent of one staff for ADL's.

2/13/25 9:02 AM - An observation of Resident R31 with bilateral contractures to bilateral upper extremities and no splints noted in place.

2/13/25 11:00 AM - An observation of Resident R31 with bilateral splints noted but not in proper placement for intended function.

2/18/25 9:40 AM - An observation of Resident R31 with bilateral contractures to bilateral upper extremities and no splints noted in place.

2/18/25 11:40 AM - An observation of Resident R31 with bilateral contractures to bilateral upper extremities and no splints noted in place.

2/18/25 11:41 AM - An interview with E12 (CNA) confirmed that Resident R31 wears bilateral hand splints and stated

they are applied in the morning and removed in the evening. E12 confirmed that the CNA is responsible to check for placement of the splint during the day and adjust if moved out of place. E12 confirmed that Resident R31's bilateral hand splints were not placed properly at time of observation.

2/19/25 9:27 AM - An observation of Resident R31 with bilateral contractures to bilateral upper extremities and no splints noted in place.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 26 085019 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085019 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Terrace Rehabilitation and Health Center 889 South Little Creek Road Dover, DE 19901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 2/19/25 10:45 AM - An interview with E26 (CNA) confirmed that Resident R31 did not have splints on and stated that another staff member told her Resident R31's bilateral splint order was discontinued. Level of Harm - Minimal harm or potential for actual harm 2/19/25 10:52 AM - An interview with E27 (COTA) confirmed that Resident R31's bilateral splint order was not discontinued. Residents Affected - Few 2/19/25 10:59 AM - An interview with E16 (LPN) confirmed that Resident R31 still had an active order in the EMR (electronic medical record) for bilateral splints and stated that she will ensure they get placed on Resident R31.

2/19/25 1:41 PM - Findings were reviewed during the exit conference with E1(NHA), and E2 (DON).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 26 085019 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085019 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Terrace Rehabilitation and Health Center 889 South Little Creek Road Dover, DE 19901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm 46988

Residents Affected - Few Based on interview and record review it was determined that for two (Resident R53 and Resident R63) out of two residents reviewed for bowel and bladder, the facility failed to provide services to maintain or restore bowel and bladder continence. Findings include:

1. Review of Resident R53's clinical record revealed:

4/5/24 - Resident R53 was admitted to the facility.

4/5/24 - A care plan was initiated for bladder incontinence related to occasionally incontinent with the following interventions: apply barrier cream with each incontinent episode, change clothing with each incontinent episode, and check resident every two hours for incontinence and provide care.

10/9/24 - A quarterly MDS assessment documented that Resident R53 required supervision of one for toileting. The MDS also documented that Resident R53 had a BIMS score of 5 indicating cognitive decline and was occasionally incontinent of bladder, always continent of bowel, and was not indicated for a toileting program.

10/2024 - A review of the October CNA documentation record revealed that Resident R53 was incontinent of urine 14 times out of 95 opportunities and incontinent of bowel 14 out of 96 opportunities.

11/4/24 - A bowel and bladder assessment documented Resident R53 was incontinent of urine and continent of bowel.

The assessment also documented that Resident R53 was aware of urges for toileting and required assistance of one for toileting.

11/2024 - A review of the November CNA documentation record revealed that Resident R53 was incontinent of urine 40 out of 93 opportunities and incontinent of bowel seven times out of 91 opportunities.

11/15/24 - A significant change MDS assessment documented that Resident R53 required supervision of one for toileting. The MDS also documented that Resident R53 was frequently incontinent of bladder, occasionally incontinent of bowel, and was not indicated for a toileting program.

12/2024 - A review of the December CNA documentation record revealed that Resident R53 was incontinent of urine 62 times out of 101 opportunities and incontinent of bowel 11 times out of 96 opportunities.

1/2025 - A review of the January CNA documentation record revealed that Resident R53 was incontinent of urine 79 times out of 102 opportunities and incontinent of bowel 13 times out of 98 opportunities.

2/2025 - A review of the February CNA documentation record revealed that Resident R53 was incontinent of urine 42 out of 49 opportunities and incontinent of bowel four times out of 55 opportunities.

2/8/25 12:45 PM - An interview with E25 (CNA) confirmed that Resident R53 was an assist of one staff for toileting and that Resident R53 can tell staff that she has to use the bathroom. E25 stated that she does not recall resident being on

a toileting program.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 26 085019 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085019 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Terrace Rehabilitation and Health Center 889 South Little Creek Road Dover, DE 19901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 The facility lacked evidence that they attempted to restore bowel and bladder function for Resident R53.

Level of Harm - Minimal harm or 2. Review of Resident R63's clinical record revealed: potential for actual harm 9/23/24 - Resident R63 was admitted to the facility. Residents Affected - Few 9/27/24 - An admission MDS assessment documented Resident R63 is dependent on staff for toileting. The MDS also documented Resident R63 was always incontinent of bowel and bladder and was not on a toileting program.

11/2024 - A review of the November CNA documentation record revealed that Resident R63 was continent of urine four times out of 96 opportunities and continent of bowel six times out of 96 opportunities.

12/2024 - A review of the December CNA documentation record revealed that Resident R63 was continent of urine two times out of 105 opportunities and continent of bowel two times out of 98 opportunities.

12/27/24 - An quaterly MDS assessment documented Resident R63 is dependent on staff for toileting. The MDS also documented Resident R63 was always incontinent of bowel and and frequently incontinent bladder and was not on a toileting program.

12/30/24 - A bowel and bladder assessment documented Resident R63 was total incontinence of urine and total incontinence of bowel. The assessment also documented that Resident R63 was unaware of urges for toileting and required complete dependence of one for toileting.

1/2025 - A review of the January CNA documentation record revealed that Resident R63 was continent of urine zero times out of 101 opportunities and continent of bowel zero times out of 98 opportunities.

2/11/25 10:20 AM - An interview with Resident R63 revealed that Resident R63 was using a bed pan prior to admission to the facility and Resident R63 stated she requested to use one and has not received one.

2/18/25 11:30 AM - An interview with E12 (CNA) confirmed that Resident R63 is dependent for care and Resident R63 is able to verbalize when she needs to use the bathroom. E12 stated that Resident R63 does not use a bed pan and has not been on a toileting program that she can recall.

The facility lacked evidence that they attempted to restore bowel and bladder function for Resident R63.

2/19/25 1:41 PM - Findings were reviewed during the exit conference with E1(NHA), and E2 (DON).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 26 085019 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085019 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Terrace Rehabilitation and Health Center 889 South Little Creek Road Dover, DE 19901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or 44706 potential for actual harm Based on observation, interview and record review, it was determined that for one (Resident R375) out of one resident Residents Affected - Few reviewed for respiratory care, the facility failed to provide professional standards of of practice by ensuring

the oxygen tubing was changed weekly and nasal cannula was stored in a bag when not in use. Findings include:

Review of Resident R375's clinical record revealed:

12/12/24 - Resident R375 was admitted to the facility.

12/12/24 - A physician order was written to administer oxygen at 2 liters/minute via nasal cannula, may titrate to maintain SpO2 90% or greater.

12/13/24 - A physician order was written to change oxygen tubing weekly and PRN (as needed) and to label tubing, date time and initial. Nasal cannula to be stored in a bag when not in use.

12/16/24 - An admission MDS indicated Resident R375 had a BIMS score of 3 (severe impairment ) and diagnoses of COPD, asthma and respiratory failure.

2/11/25 10:29 AM - An observation of Resident R375's oxygen tubing revealed a label dated 1/30/25, no time or initial. Oxygen tubing was on the floor beside Resident R375's bed.

2/11/25 11;12 AM - During an interview, E15 (LPN) confirmed that the tubing was labeled 1/30/25, no time or initial and the oxygen tubing was on the floor.

2/12/25 1:20 PM - An observation revealed Resident R375 was in bed with nasal cannula applied, tubing was still labeled 1/30/25.

2/12/25 approximately 1: 40 PM - During an interview, E21 (Regional Corporate Consultant) confirmed the oxygen tubing needed to be changed and stated I'll take care of it.

2/19/25 1:41 PM - Findings were reviewed during the exit conference with E1(NHA), and E2 (DON).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 26 085019 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085019 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Terrace Rehabilitation and Health Center 889 South Little Creek Road Dover, DE 19901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Minimal harm or 46988 potential for actual harm Based on observation, interview, and record review it was determined that for three (Resident R63, Resident R53, and Resident R59) out Residents Affected - Some of three residents reviewed for pain, the facility failed to ensure that that adequate pain management was provided and pain assessments were not conducted with a consistent scale for pre and post pain assessments. Findings include:

April 2002 - The pain management standards by the American Geriatrics Society included: appropriate assessment and management of pain; assessment in a way that facilitates regular reassessment and follow-up; same quantitative pain assessment scales should be used for initial and follow up assessment; set standards for monitoring and intervention; and collect data to monitor the effectiveness and appropriateness of pain management.

November 2009 - The American Academy of Pain Medicine, Pharmacological Management of Persistent Pain in Older persons, stated to refer to the previous American Geriatrics Society for specific recommendations for pain assessment in older persons that remain relevant.

1. Review of Resident R63's clinical record revealed:

9/23/24 - Resident R63 was admitted to the facility with the diagnoses including chronic pain, venous insufficiency, and cellulitis.

9/25/24 - A care plan for Resident R63 was initiated for pain related to chronic pain with the following interventions: administer analgesia per orders, monitor and document side effects from pain medication, monitor/record/report to nurse any signs and symptoms of pain to the nurse, and notify the physician if interventions are unsucessful or if current complaint is a significant change from resident's experience of pain.

9/27/24 - An admission MDS documented Resident R63 was receiving scheduled pain medication, as needed pain medication, pain frequency is occasional, and level of 3/10 as highest pain level in the last 5 days.

11/12/24 - A physician's order for Resident R63 documented Tramadol 50 mg give one tablet by mouth every six hours for moderate and severe pain as needed and give thirty minutes prior to wound care.

11/2024 - A review of the November MAR revealed that Resident R63 received Tramadol one time out of the 18 ordered opportunities to be given.

12/2024 - A review of the December MAR revealed that Resident R63 received Tramadol one time out of the 31 ordered opportunities to be given.

1/2025 - A review of the January MAR revealed that Resident R63 received Tramadol zero times out of the 31 ordered opportunities to be given.

2/11/25 10:15 AM - An interview with Resident R63 revealed that Resident R63 was having bilateral lower leg pain at a score of 7-8 out of 10. Resident R63 stated she had received Tylenol for pain and it was ineffective and she had told the doctor previously that Tylenol does not help her pain.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 26 085019 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085019 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Terrace Rehabilitation and Health Center 889 South Little Creek Road Dover, DE 19901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 2/13/25 11:11 AM - An observation of Resident R63's wound care treatment revealed that Resident R63 stated she had pain of 5/10 prior to administration of the treatment. Resident R63 confirmed she was a 10/10 during treatment and 10/10 Level of Harm - Minimal harm or after treatment. An observation of resident yelling out every time E20 (LPN) would touch an area on Resident R63's potential for actual harm left lower extremity. Resident R63's bilateral lower extremities were covered in crusted scab like areas and when touched the crusted area would come off and revealed reddened tissue underneath. Resident R63 stated that the Residents Affected - Some liquid (acetic acid) that E20 was applying to her legs was burning and stinging when applied.

2/13/25 11:25 AM - An interview with E20 revealed that she administered Tylenol 650 mg to Resident R63 despite the order in the EMR stated to give Tramadol (pain medication) 50 mg 30 minutes prior to wound care.

2/13/25 2:37 PM - An interview with E20 confirmed she only administers the Tramadol when Resident R63 complains of moderate or severe pain. E20 confirmed that she usually gives Resident R63 Tylenol prior to wound care and today

she did because resident complained of 5/10 pain.

2/14/25 12:31 PM - An interview with E9 (MD) confirmed that the Tramadol was to be administered 30 minutes prior to Resident R63 receiving wound care to control pain. E9 was unaware staff was not administering the Tramadol per order.

2/14/25 1:00 PM - An interview with Resident R63 confirmed she received Tramadol per order and her legs are less painful today.

2/2025 - A review of the February MAR revealed that Resident R63 received Tramadol four times out of the 13 opportunities to be given.

The facility failed to administer pain medication prior to wound care treatment per physician's order.

2. Review of Resident R53's clinical record revealed:

4/5/24 - Resident R53 was admitted to the facility.

4/5/24 - A care plan was initiated and documented that Resident R53 had pain related to generalized pain, diagnosis of pain in joints, right shoulder pain, and hemrorroid pain. Interventions included notify physician if interventions are unsuccessful and observe and report any changes in usual routine, sleep pattern, or if current pain complaint is a significant change from baseline.

4/18/24 - An admission MDS documented that Resident R53 was on a scheduled pain regimen and had constant pain.

12/2024 - A review of Resident R53's December MAR revealed that Resident R53's pain was not being monitored every shift and PRN (as needed) medications were being administered with a numerical pre pain score and post score documented as ineffective, effective, and unchanged. Resident R53 received four doses of Tylenol out of 30 potential opportunities with the incorrect pain scale used pre and post administration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 26 085019 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085019 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Terrace Rehabilitation and Health Center 889 South Little Creek Road Dover, DE 19901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 1/2025 - A review of Resident R53's January MAR revealed that Resident R53's pain was not being monitored every shift and PRN (as needed) medications were being administered with a numerical pre pain score and post score Level of Harm - Minimal harm or documented as ineffective, effective, and unchanged. Resident R53 received four doses of Tylenol out of 30 potential potential for actual harm opportunities with the incorrect pain scale used pre and post administration.

Residents Affected - Some 2/2025 - A review of Resident R53's February MAR revealed that Resident R53's pain was not being monitored every shift and PRN (as needed) medications were being administered with a numerical pre pain score and post score documented as ineffective, effective, and unchanged. Resident R53 received one dose of Tylenol out of 30 potential opportunities with the incorrect pain scale used pre and post administration.

2/11/25 9:42 AM - An interview with Resident R53 revealed that she is having left knee pain and Tylenol is not effective.

2/14/25 12:31 PM - An interview with E2 (DON) and E19 (Corporate) confirmed that Resident R53's pain was not being monitored and the pain scale did not match pre and post assessment.

The review of Resident R53's medical record revealed that the facility failed to monitor pain with a consistent scale.

3. Review of Resident R59's clinical record revealed:

12/23/23 - Resident R59 was admitted to the facility.

1/8/24 - A review of the care plan lacked evidence of a pain care plan.

1/19/24 - An admission MDS documented that Resident R59 was on a scheduled pain medication and did not have pain currently.

12/2024 - A review of Resident R59's December MAR revealed that Resident R59's pain was not being monitored every shift and PRN (as needed) medications were being administered with a numerical pre pain score and post score documented as ineffective, effective, and unchanged. Resident R59 received four doses of Tylenol out of 30 potential opportunities with the incorrect pain scale used pre and post administration.

1/2025 - A review of Resident R59's January MAR revealed that Resident R59's pain was not being monitored every shift and PRN (as needed) medications were being administered with a numerical pre pain score and post score documented as ineffective, effective, and unchanged. Resident R59 received one dose of Voltaten (topical pain cream) out of 30 potential opportunities with the incorrect pain scale used pre and post administration.

2/2025 - A review of Resident R59's February MAR revealed that Resident R59's pain was not being monitored every shift and PRN (as needed) medications were being administered with a numerical pre pain score and post score documented as ineffective, effective, and unchanged. Resident R59 received two doses of Tylenol and five doses of Voltaren out of 30 potential opportunities with the incorrect pain scale used pre and post administration.

2/18/25 09:30 AM - An interview with Resident R59 revealed she is having bilateral knee pain and Tylenol is not effective.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 26 085019 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085019 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Terrace Rehabilitation and Health Center 889 South Little Creek Road Dover, DE 19901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 2/14/25 12:31 PM - An interview with E2 (DON) and E19 (Corporate) confirmed that Resident R59's pain was not being monitored and the pain scale did not match pre and post assessment. Level of Harm - Minimal harm or potential for actual harm The review of Resident R59's medical record revealed that the facility failed to monitor pain with a consistent scale.

Residents Affected - Some 2/19/25 1:41 PM - Findings were reviewed during the exit conference with E1(NHA), and E2 (DON).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 26 085019 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085019 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Terrace Rehabilitation and Health Center 889 South Little Creek Road Dover, DE 19901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Potential for minimal harm 46988

Residents Affected - Many Based on record review and interview, it was determined that the facility failed to develop policies and procedures for the monthly MRR (Medication Regimen Reviews) that included time frames for different steps

in the MRR process. Findings include:

1/2025 - Review of the facilities undated policy titled, Medication Regimen Review, lacked information regarding the time frames for a pharmacist response for urgent recommendations.

2/14/25 9:55 AM - An interview with E2 (DON) and E19 (Corporate) confirmed the policy was current.

The facilities policy did not meet expected requirements to address timeframes for urgent recommendations.

2/19/25 1:41 PM - Findings were reviewed during the exit conference with E1(NHA), and E2 (DON).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 26 085019 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085019 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Terrace Rehabilitation and Health Center 889 South Little Creek Road Dover, DE 19901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0791 Provide or obtain dental services for each resident.

Level of Harm - Minimal harm or 46988 potential for actual harm Based on observation, interview and record review, it was determined that for two (Resident R59 and Resident R63) out of two Residents Affected - Few sampled residents for dental services, the facility failed to assist the residents in obtaining routine dental services. Findings include:

1. Review of Resident R59's clinical record:

1/8/24 - Resident R59 was admitted to facility.

4/4/24 - A review of Resident R59's care plan documented Resident R59 has a risk for an alteration in nutrition/hydration secondary to dementia, type II diabetes, and hypertension. The interventions included the following but not limited to explain and reinforce the importance of maintaining diet ordered and educate on refusals and risks.

The care plan lacked evidence of a care plan relating to dental concerns.

12/17/24 - An annual MDS documented Resident R59 had no natural teeth, no broken or loosely fitting dentures/partials, and no mouth or tooth pain.

2/11/25 9:37 AM - An interview with Resident R59 revealed that Resident R59 did not have dentures and complained of difficulty chewing due to not having dentures. Resident R59 stated she wanted to see a dentist and had not been offered to see one.

2/18/25 2:53 PM - An interview with E1 (NHA) and E24 (Corporate) confirmed Resident R59 had not seen the dentist or had been offered dental services.

2. Review of Resident R63's clinical record revealed:

9/23/24 - Resident R63 was admitted to the facility.

9/25/24 - A review of Resident R63's care plan documented Resident R63 had a potential for ADL self care deficit related to limited mobility. Interventions included assistance of one staff member for personal hygiene and oral care.

The care plan lacked evidence of a care plan relating to dental concerns.

12/23/24 - A quarterly MDS assessment documented that Resident R63 did not have broken or loosely fitting dentures and Resident R63 had no mouth or facial discomfort.

2/11/25 10:25 AM - An interview with Resident R63 revealed that she had not seen a dentist since admission and Resident R63 would like to receive dental services.

2/18/25 2:53 PM - An interview with E1 (NHA) and E24 (Corporate) confirmed Resident R63 had not seen the dentist or had been offered dental services.

The facility failed to offer dental services to Resident R53 and Resident R63.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 26 085019 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085019 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Terrace Rehabilitation and Health Center 889 South Little Creek Road Dover, DE 19901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0791 2/19/25 1:41 PM - Findings were reviewed during the exit conference with E1(NHA), and E2 (DON).

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 26 085019 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085019 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Terrace Rehabilitation and Health Center 889 South Little Creek Road Dover, DE 19901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 32810

Residents Affected - Some Based on observation and interview it was determined that the facility failed to ensure food was stored, prepared, and served in a manner that prevents food borne illness to the residents. Findings include:

1. 2/11/25 8:39 AM - During the initial tour of the kitchen the surveyor observed the following:

- The hair on the front of E5's (FSS) head was unsecured by a hair net.

- The hand washing sink located in the dish area was obstructed by a fan and the paper towel dispenser was empty.

- The small refrigerator for milk storage contained an opened gallon of milk with an expiration date of 2/5/25.

38302

2. 2/17/25 10:06 AM - During a tour of the kitchen, food particles were splattered on the top and sides of the cooktop and oven. Food debris and other litter was on the kitchen floor, under the shelving, prep trables and oven.

2/17/25 11:05 AM - The underside of all of the shelves on the plastice shelving units in the walk-in refrigerator had numerous areas of small black circular staining, which appeared to be mold or mildew creating the potential for contamination of food items stored there.

2/17/25 11:40 AM - During a tour of the kitchen, the walk-in refrigerator contained a pan of sausage patties, which was not completely covered exposing it to contamination from dust and other debri

2/19/25 1:41 PM - Findings were reviewed during the exit conference with E1(NHA), and E2 (DON).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 26 085019