Silver Lake Center

F-F600)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 31 085027 Department of Health & Human Services Printed: 09/10/2025 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 085027 B. Wing 01/23/2025

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

Complete Care at Silver Lake LLC 1080 Silver Lake Blvd Dover, DE 19904

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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36190 potential for actual harm Based on observation, interview, and facility policy review, the facility failed to serve food that was palatable Residents Affected - Few and at the appropriate temperature for three of five residents (Resident (R) 62, Resident R46, and Resident R11) reviewed for food palatability out of 32 sample residents. This deficient practice could potentially cause residents to lose weight and decrease quality of life.

Findings include:

Review of the facility's policy titled, Food: Quality and Palatability, revised 2/2023, revealed . Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature .

Review of the Centers for Disease Control website, located at https://www.cdc. gov/covid/hcp/infection-control/index.html, revealed, . Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic . Management of laundry, food service utensils, and medical waste should be performed in accordance with routine procedures .

Review of the Resident Council Minutes, dated 12/20/24 and provided by the facility, revealed two complaints of cold food. The resolution included Will follow for trend.

1. Review of Resident R62's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 12/30/24 and located in the MDS tab of the electronic medical record (EMR), revealed an admitted [DATE REDACTED] and a Brief Interview for Mental Status (BIMS) of 14 out of 15, indicating Resident R62's cognition was intact. It was recorded that Resident R62 had diagnoses of diabetes mellitus, hypertension, and chronic obstructive pulmonary disease.

Review of Resident R62's Care Plan, dated 06/28/23 and located in the EMR under the Care Plan tab, revealed, The resident has nutritional problem r/t [related to] therapeutic diet restrictions, morbid obesity. An intervention included, . Provide, serve diet as ordered. Monitor intake and record q [every] meal .

Review of Resident R62's Orders, dated 01/16/25 and located in the EMR under the Order tab, revealed Infection Precautions - droplet, contact for covid positive.

During an interview on 01/20/25 at 3:09 PM, Resident R62 voiced complaints about being served cold food. Resident R62 stated the noodles, carrots, and rice were not cooked well.

During an observation and interview on 01/22/25 at 12:37 PM, Resident R62 was served lunch in her room in a disposable foam tray. Resident R62's meal included chicken, mixed vegetables, fruit, noodles, and a roll. Resident R62 stated her food was not warm but she was going to eat it anyway.

During an observation and interview on 01/23/25 at 8:07 AM, Resident R62 was served breakfast in her room in a disposable foam tray. Resident R62's meal included fried eggs, toast, and cream of wheat. Resident R62 stated her food was served cold.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 31 085027 Department of Health & Human Services Printed: 09/10/2025 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 085027 B. Wing 01/23/2025

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

Complete Care at Silver Lake LLC 1080 Silver Lake Blvd Dover, DE 19904

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 0804 During an observation and interview on 01/23/25 at 12:40 PM, Resident R62 was served lunch in her room in a disposable foam tray. Resident R62's meal included chicken, stuffing, Brussel sprouts, fruit, and a roll. Resident R62 stated, It's Level of Harm - Minimal harm or not warm, just not warm enough. potential for actual harm

During an interview on 01/23/25 at 8:04 AM, the Dietary Manager (DM) was asked why disposable foam Residents Affected - Few trays were used. The DM stated they were used for COVID positive residents only. The DM was asked if he was aware of cold food complaints. The DM stated they just changed the delivery service last night to help with keeping the food warm. The DM stated all the COVID trays were now placed on one cart to help with faster hall tray service and retain heat because the foam trays were not insulated. The DM stated he was not aware of the newest CDC guidance for COVID residents that stated routine management of food service utensils should be used.

During an interview on 01/23/25 at 1:48 PM, the Registered Dietitian (RD) was asked about the cold food complaints residents had during the survey. These residents received their meals in the disposable foam trays. The RD stated the foam trays were used to serve residents their meals in their rooms for the COVID outbreak. The RD was asked about her expectations for keeping the food warm. RD stated, Get back to the system of regular utensils as soon as possible.

2. Review of Resident R46's Admission Record, located under the Profile tab of the EMR, revealed Resident R46 was admitted

on [DATE REDACTED] with diagnoses of type two diabetes and acquired absence of right leg below the knee.

Review of Resident R46's quarterly MDS, located in the EMR under the MDS tab and with an ARD of 01/05/25, revealed the resident had a BIMS score of 15 out of 15, indicating Resident R46 was cognitively intact.

During an interview on 01/20/25 at 2:55 PM, Resident R46 said she had concerns with the food. She said she used to work in the kitchen and the food was disgusting. She said the kitchen just don't know how to fix food.

During an interview on 01/22/25 at 1:25 PM, Resident R46 said the food was cold today and didn't look appetizing.

She said the cabbage was not cooked either. She said because of the way it looked; she ordered out. Resident R46 said the food was always cold.

3. Review of Resident R11's Orders tab of the EMR revealed Resident R11 was admitted to the facility on [DATE REDACTED] with diagnoses that included dementia and multiple sclerosis (a chronic disease that affects the central nervous system.)

Review of Resident R11's quarterly MDS, with an ARD of 11/24/24 and located in the EMR under MDS tab, revealed Resident R11 had a BIMS score of 12 out of 15, which indicated Resident R11 had moderate cognitive impairment.

During an interview on 01/21/25 at 10:27 AM, Resident R11 stated the food was not good and it was cold. Resident R11 stated, If I do not like it, I do not eat it. Resident R11 stated he usually ordered food for delivery.

During an observation on 01/23/25 at 7:58 AM, Resident R11's meal arrived in Styrofoam dishes (which could contribute to foods cooling rapidly), and it was the last tray to be served from the cart that arrived on the unit at 7:33 AM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 31 085027 Department of Health & Human Services Printed: 09/10/2025 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 085027 B. Wing 01/23/2025

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

Complete Care at Silver Lake LLC 1080 Silver Lake Blvd Dover, DE 19904

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 0804 4. On 01/23/25 at 7:44 AM, a test tray containing coffee, juice, sausage, pancakes, and oatmeal was obtained. The food temperatures were tested by the Dietary Manage (DM) using a new Level of Harm - Minimal harm or potential for actual harm thermometer which could not be calibrated. The oatmeal temperature registered at 135 degrees Fahrenheit (F); however, the surveyor noted the oatmeal to taste lukewarm. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 31 085027 Department of Health & Human Services Printed: 09/10/2025 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 085027 B. Wing 01/23/2025

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

Complete Care at Silver Lake LLC 1080 Silver Lake Blvd Dover, DE 19904

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 36190

Residents Affected - Many Based on observation, interviews, and facility policy review, the facility failed to ensure cold storage units contained interior temperature gauges, kitchen floors and walls were kept clean and in good repair, and leftovers were cooled down correctly, in one of one kitchen. This deficient practice had the potential to affect 107 of 107 residents who received meals prepared in the facility. This failure had the potential to affect the spread of food borne illness.

Findings include:

Review of the facility's policy titled, Sanitation Inspection, revised 03/29/23, revealed It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations. 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects. 2. The department shall establish a sanitation program for food services based on applicable state and federal requirements. 4. Sanitation inspections will be conducted in the following manner: a. Daily: Food service staff shall inspect refrigerators/coolers, freezers, storage area temperatures, and dishwasher temperatures daily.

Review of the United States Food & Drug Administration Food Code 2022, dated 01/18/23 and located at https://www.fda.gov/media/164194/download?attachment, revealed 3-501.14 Cooling. (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57 C (135 F [Fahrenheit]) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less.

During the kitchen tour on 01/20/25 at 10:45 AM with the Dietary Manager (DM), the following observations were made:

1. The walls throughout the kitchen contained a collection of dried splatters, notably in and around the coffee and tea station, the range, the hand sink, along the lower walls at the reach-in refrigerator, and under the dish machine. An accumulation of food and dust debris was noted along the wall strips and on and around electrical switches. The strips along the lower walls were broken and an accumulation of a dark substance was noted at the wall tile and floor junctures. The door frames were gouged, exposing raw wood.

2. Four cold storage units did not contain a temperature gauge inside. These units included the first reach-in refrigerator located in the food storage room storing produce, the reach-in freezer storing ice cream, the reach-in freezer with vegetables, and the milk box in the food storage room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 31 085027 Department of Health & Human Services Printed: 09/10/2025 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 085027 B. Wing 01/23/2025

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

Complete Care at Silver Lake LLC 1080 Silver Lake Blvd Dover, DE 19904

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 3. The second reach-in refrigerator located in the food storage room was observed to have containers of pureed scrambled eggs, regular scrambled eggs, and link sausage. The DM stated these containers were Level of Harm - Minimal harm or leftovers from 01/20/25 at breakfast and they were taken off the steamtable at 8:00 AM. The DM was asked potential for actual harm to take the temperature of the leftovers. The containers of pureed scrambled eggs measured 96 degrees F, regular scrambled eggs measured 86 degrees F, and link sausage measured 75 degrees F. The DM was Residents Affected - Many asked if he was aware the temperature of the leftovers should be at 70 degrees F within two hours. However, two hours and 45 minutes had lapsed, and the temperatures were greater than 70 degrees F. The DM stated, Yes, they use ice baths to cool foods, but not today due to short staff. The DM then placed the containers back into the refrigerator.

4. On 01/22/25 at 8:32 AM, the walls were again observed throughout the kitchen containing a collection of dried splatters, notably in and around the coffee and tea station, the range, the hand sink, along the lower walls at the reach-in refrigerator, and under the dish machine. An accumulation of food and dust debris was noted along the wall strips and on and around electrical switches. The strips along the lower walls were broken and an accumulation of a dark substance was noted at the wall tile and floor junctures. The door frames were gouged, exposing raw wood. The DM was asked about the walls and tile build-up. The DM stated the kitchen was responsible for the walls but housekeeping and maintenance were responsible for the tile and floors as they have the proper tools to scrape off the build-up, but the kitchen staff only had a mop.

The DM was asked for a working copy of the kitchen's cleaning schedule. The DM stated, it's not posted this week. The DM was asked to provide a copy of what the kitchen was to use. The DM then searched on his computer for a copy and was unable to locate it.

5. On 01/22/25 at 8:42 AM, a pan of ice was observed with three containers of food on top of the ice. The Dietary Assistant Account Manager (DAAM) stated the food was from 01/22/25 at breakfast. These included

a pan of sausage, regular scrambled eggs, and pureed scrambled eggs which were 10 inches full and warm to touch. The DAAM was asked about the full container of eggs and would the temperature get to 70 degrees F in two hours. The DAAM stated, Yes.

On 01/22/25 at 11:35 AM, a follow-up was conducted on the leftovers. The DM was asked to take the temperature of the pureed eggs in the 10-inch container. The pureed eggs measured 93.5 degrees F. The DAAM stated the eggs were taken from the steam table at 7:50 AM on 01/22/25. However, three hours and 45 minutes had lapsed, and the temperatures were greater than 70 degrees F.

6. During an interview on 01/23/25 at 1:48 PM, the Registered Dietitian (RD) was asked about the incorrect cooling down of leftovers observed on 1/20/25 and 1/22/25. The RD stated she wasn't told that the leftovers were incorrectly cooled down and weren't in a shallow pan. The RD asked what her expectation was for the kitchen to cool down leftovers. The RD stated, the kitchen shouldn't have any leftovers but if they do, they should be in a shallow pan as that's the way to cool it down the fastest. The RD was asked about the kitchen walls and floors in need of cleaning. The RD stated she identified dirty and stained walls in her last monthly sanitation report and confirmed they needed thorough cleaning.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 31 085027 Department of Health & Human Services Printed: 09/10/2025 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 085027 B. Wing 01/23/2025

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

Complete Care at Silver Lake LLC 1080 Silver Lake Blvd Dover, DE 19904

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28306 potential for actual harm Based on observation, record review, and interview, the facility failed to 1.) complete wound care in a Residents Affected - Some manner to prevent cross contamination for one of one resident (Resident (R) 78) reviewed for wound care out of a total sample of 32, and 2.) wear the proper Personal Protective Equipment (PPE) when entering into

a contact isolation room for one of 27 residents (room [ROOM NUMBER]) noted to be COVID positive.

These failures put the vulnerable population of residents at greater risk of developing infections and the increased risk of staff spreading infections throughout the facility by not adhering to the isolation precautions.

Findings include:

1.Review of Resident R78's undated Face Sheet, located under the Profile tab in the electronic medical record (EMR), revealed Resident R78 was admitted to the facility on [DATE REDACTED] with diagnoses of dementia, chronic obstructive pulmonary disease, and chronic kidney disease.

Review of Resident R78's quarterly Minimum Data Set (MDS), located under the MDS tab in the EMR and with an Assessment Reference Date (ARD) of 11/14/24, revealed Resident R78 was at risk for developing a pressure ulcer. It was recorded Resident R78 had a Brief Interview for Mental Status (BIMS), score of three out of 15, which indicated

the resident was severely cognitively impaired.

Review of Resident R78's Care Plan, located under the Care Plan tab in the EMR and dated 12/31/24, indicated, . The resident [Resident R78] has open [sic] area on his sacrum r/t [related to] incontinence/ immobility . Interventions were, . Assess characteristics of wound, including color, size (length, width, depth), drainage, and color. Low air mattress at 200 [sic]. Monitor site of impaired tissue integrity for color changes, redness, swelling, warmth, pain, or other signs of infection. Provide skin tissue care as needed .

Review of Resident R78's Physician Orders, located under the Orders tab in the EMR and dated 01/16/25, revealed, . Sacrum Stage 3 [sic]. Cleanse with NS [Normal Saline], apply medical grade honey, cover with bordered gauze daily and PRN [as needed] [sic] .

During the wound care observation on 01/22/25 at 3:20 PM, Registered Nurse (RN) 2, the following failures were noted with wound care: 1) RN2 sprayed Saline Wound Cleanser to a clean 4x4 gauze pad and then patted all areas of the wound bed with the same 4x4. 2) RN2 applied the medical grade honey to the wound bed with a clean Q tip. As she was applying the honey, a small amount of honey dropped to the intact skin below the wound. RN2 took the Q tip and pushed the honey into the wound bed. 3) During the wound care

observation, the front of RN2's gown came down to the breast area, exposing RN2's uniform. The theRN2 right arm sleeve of the gown came off her shoulder and was down to the elbow area of RN2. This also exposed RN2's uniform. 4) RN2 brought the spray bottle of saline wound cleanser out of Resident R78's room and placed it back into the bottom drawer of the wound cart without first cleaning the bottle.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 31 085027 Department of Health & Human Services Printed: 09/10/2025 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 085027 B. Wing 01/23/2025

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

Complete Care at Silver Lake LLC 1080 Silver Lake Blvd Dover, DE 19904

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 0880 During an interview on 01/22/24 at 3:50 PM, RN2 stated, I should have fastened the top of my gown before I started the wound care so it wouldn't slide down. I should have also cleaned the bottle of saline wound Level of Harm - Minimal harm or cleanser with a disinfectant wipe before putting it in the bottom of the wound cart. When asked if RN2 all potential for actual harm areas of the wound bed should have been wiped with one 4x4, RN2 stated, No, I should have gotten a new one before I wiped it the second time. RN2 was asked if she should have pushed the honey from the skin Residents Affected - Some below the wound to the middle of the wound bed, and she replied, I didn't think it was dirty.

During an interview on 01/23/25 at 12:08 PM, the Director of Nursing (DON) stated, I expect the nurse to clean the wound bed using a circular motion with one 4x4 then discard it and then get a clean 4x4 to clean

the wound bed again. [Resident R78] was positive for COVID so nothing should have been brought out of his room that the nurse took into the room for wound care. The nurses' gown should have been fastened at the top to prevent her scrubs from getting contaminated due to the resident having COVID.

During an interview on 01/23/25 at 5:11 PM, the Infection Preventionist (IP) stated, The nurse's gown should have been tied at the top or the strap placed over her head so the gown would not slide down. The nurse should clean the wound in a circle, getting a clean 4x4 each time this is done. The saline wound cleanser should not have been brought out of the resident's room because he [Resident R78] is in contact isolation.

2. During an interview on 01/20/25 at 9:45 AM, the Director of Nursing (DON) reported the facility currently had 27 residents who were in droplet precautions after testing positive for the COVID virus, or who had close contact with a resident who tested positive.

On 01/20/25 at 11:28 AM, Housekeeper (HSK) 1 went into room [ROOM NUMBER] to clean the room. Posted on the room's door frame was a sign indicating droplet precautions were in place. The sign directed staff to sanitize their hands and don a gown, gloves, N95 mask, and an eye shield prior to entering the room and to discard them prior to leaving the room. HSK1 entered room [ROOM NUMBER], wearing an N95 mask and gloves. No gown or face shield were used. While cleaning the room, HSK1 exited the room twice while wearing gloves and the N95 mask, took several steps to the cart, and replaced or obtained cleaning supplies without discarding the N95 mask and gloves or completing hand hygiene.

During an interview on 01/20/25 at 11:40 AM, HSK 1 acknowledged the error and stated the guidelines posted outside the room should have been followed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 31 085027 Department of Health & Human Services Printed: 09/10/2025 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 085027 B. Wing 01/23/2025

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

Complete Care at Silver Lake LLC 1080 Silver Lake Blvd Dover, DE 19904

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 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or 12273 potential for actual harm Based on interview, record review, and facility policy review, the facility failed to ensure the Antibiotic Residents Affected - Many Stewardship Program was consistently implemented. The facility failed to document criteria for the use of antibiotics, antibiotics used, and results of culture and sensitivity testing. The facility failed to analyze antibiotic stewardship data to plan process improvements. This failure placed all 111 of 111 residents at risk for adverse events related to administration of antibiotics.

Findings include:

Review of the facility's policy titled, Antibiotic Stewardship Program, dated 08/02/24, indicated, . Antibiotic Use Protocols. i. Nursing staff shall complete an SBAR [Situation, Background, Assessment, Recommendation] noted to notify the physician. ii. Laboratory testing shall be in accordance with current standards of practice. iii. The facility uses updated McGeer criteria to define infections. iv. The Loeb Minimum Criteria is used to determine whether to treat an infection with antibiotics. V. All prescriptions shall specify the dose, duration and indication for use. b. Monitoring Antibiotic use. i. Monitor response to antibiotics, and lab results when available, to determine if the antibiotic is still indicated or adjustments should be made (e.g.an antibiotic time-out). ii. Antibiotic orders obtained on admission, whether new or readmission, to the facility should be reviewed for appropriateness. iii. Antibiotic orders obtained on admission from consultants, specialty, or emergency providers shall be reviewed for appropriateness. iv. Monitor during each monthly medication review when the resident is prescribed antibiotics v. Random audits of antibiotic prescriptions for shall be performed to verify completeness and appropriateness. vi. At least one outcome measure associated will be tracked monthly as prioritized by the infection control risk assessment or other surveillance data .

The protocols indicated the Infection Preventionist, Administrator and Physicians were responsible for implementing the Antibiotic Stewardship program.

During an interview on 01/23/25 at 10:45 AM, the Infection Preventionist (IP) stated the facility maintained a monthly line listing of the resident infections. When asked how IP received information about antibiotic use,

she stated they got notified if an order for antibiotics was initiated. When asked about monthly summary reports, the IP explained she was new to the facility and the role of IP and would ask the former IP who was now the Director of Nursing (DON). The DON stated she had completed monthly summaries of the line listings. When asked if they kept any floor plans that identified the location of the infections treated (to observe for clusters or trends) the DON and IP reported they did not. The DON then provided six months of logs and monthly summaries.

Review of the January 2025 Monthly Infection Surveillance Log (MISL), revealed 12 of 22 entries on the log identifying the residents were treated with antibiotics; however, the data was incomplete. Missing information included if the criteria for the definition of an infection was met (McGeers), the name of the antibiotic that was administered, and/or the results of culture and sensitivity testing (to ensure the antibiotic would be effective).

Review of logs dated September 2024 through December 2024, revealed a pattern of missing data.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 31 085027 Department of Health & Human Services Printed: 09/10/2025 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 085027 B. Wing 01/23/2025

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

Complete Care at Silver Lake LLC 1080 Silver Lake Blvd Dover, DE 19904

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 0881 Review of the December 2024 Monthly Infection Surveillance Summary Report (MISSR) Page 1 showed the percentage of patients with an infection was 18.8%. There was no documented evidence that the facility Level of Harm - Minimal harm or used data from the MISL or MISSR to analyze trends or patterns or to identify potential areas for potential for actual harm improvement.

Residents Affected - Many During an interview on 01/23/25 at 3:30 PM, the IP confirmed the missing data on the MISL.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 31 085027