Encore At West Meadow

F 0658

Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or potential for actual harm

Based on record review and interview, it was determined that for four (Resident R1, Resident R2, Resident R3, Resident R4) out of four residents reviewed for admission, the facility failed to provide services that meet the professional standard of quality as defined by the Delaware State Code regarding RN (registered nurse), LPN (licensed practical nurse) and NA (nurse aide)/ UA (unlicensed assistant) Duties for admission assessments. Findings include: Delaware State Board of Nursing - RN, LPN and NA/UAP Duties 2024 .admission Assessments *. RN (registered nurse) . *Once a care plan is established, the LPN may do assessments. Updated 10/11/24Facility admission Assessment and Follow Up: Role of the Nurse policy included a document that listed all the evaluations in the facility EMR that were considered admission Evaluations. The list included: N Adv- Clinical Admission, N Adv- Skin Check, N Adv- Braden scale- for Predicting Pressure Ulcer Risk Evaluation, N Adv- Lift/Transfer Evaluation, N Adv -Fall Risk Evaluation, N Adv -Dehydration Risk Evaluation, N Adv- Elopement Evaluation, Hot Liquids Safety Data Collection, Functional Abilities and Goals, LCS Bedrail Evaluation, Trauma Informed Care and Baseline Care Plan.1. Review of Resident R1's clinical

record revealed:8/5/25 - Resident R1 was readmitted to the facility.8/5/25 - E6 (LPN) documented and completed in Resident R1's EMR the N Adv-Clinical Admission, N Adv-Braden Scale- for Predicting Pressure Ulcer Risk Evaluation, N Adv- Left/Transfer Evaluation, N Adv-Elopement Evaluation, Functional Abilities and Goals, and N Adv- Dehydration Risk Evaluation.The facility failed to have a registered nurse complete six of Resident R1's admission evaluations.2. Review of Resident R2's clinical record revealed: 10/26/25 - Resident R2 was admitted to the facility.10/26/25 - E11 (LPN) documented and completed in Resident R2's EMR the N Adv-Clinical Admission, N Adv-Braden Scale- for Predicting Pressure Ulcer Risk Evaluation, N Adv-Elopement Evaluation, N Adv- Fall Risk Evaluation and N Adv- Dehydration Risk Evaluation.The facility failed to have a registered nurse complete five of Resident R2's admission evaluations.3. Review of Resident R3's clinical record revealed: 10/10/25 - Resident R3 was admitted to the facility.10/10/25 - 10/26/25 - E12 (LPN) documented and completed in Resident R3's EMR the N Adv-Clinical Admission, N Adv-Trauma Informed Care, N Adv-Elopement Evaluation, N Adv- Fall Risk Evaluation, N Adv- Lift/Transfer Evaluation and N Adv- Dehydration Risk Evaluation.The facility failed to have a registered nurse complete six of Resident R3's admission evaluations.4. Review of Resident R4's clinical record revealed: 10/4/25 - Resident R4 was admitted to the facility.10/4/25 - 10/26/25 - E6 (LPN) documented and completed in Resident R4's EMR the N Adv-Clinical Admission, N Adv-Elopement Evaluation, N Adv- Fall Risk Evaluation, N Adv- Lift/Transfer Evaluation and N Adv- Dehydration Risk Evaluation.The facility failed to have a registered nurse complete five of Resident R4's admission evaluations.10/29/25 12:35 PM - During an interview, E2 (DON) confirmed that E6, E11 and E12 had completed several of the facility's admission evaluations. 10/29/25 1:45 PM- The findings were reviewed during the exit conference with E1(NHA), E2 (DON), E3 (RDOCS), E4 (RN/UM) and E5 (RN/UM).

Residents Affected - Some

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Encore at West Meadow

255 Possum Park Road Newark, DE 19711

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

residing in the SNF (skilled nursing facility). Their (Resident R1's) profile was in the IL (independent living). We did not have any allergy information so we had to call the IL to get allergies. On 8/6/25, the facility called and was told there was no script (prescription). The script was associated with the IL. The problem was [Resident R1] was profiled as residing in the IL, where she normally lives. The pharmacy did not know she had been to the hospital and was now in rehab at the SNF. We (pharmacy) typically try not to admit or move the patients in

the profiles until they are actually in the facility as this creates an insurance reimbursement issue if the resident ends up not showing up at the facility. On 8/7/25, the facility got the MD (medical doctor) to fill out a new script. He (C1, DO) wrote for 1mg (milligram) of lorazepam BID (twice a day) but the formulation of lorazepam in the E box (emergency medication box) was 0.5 mg, the pharmacy could not release the medication. The script (prescription) has to match the drug formulation in the E box exactly or regulation or

we cannot release the medication. So although there was lorazepam available in the facility, we could not release the medication. We needed the script to say lorazepam 0.5mg four tablets for a 2 mg dose in order to use the meds (medication) for the E box.10/29/25 1:15 PM - During an interview, E10 (RN) stated that on 8/7, she had requested that C1 write a new script with the available formulation in the E box for the lorazepam, which was 0.5 mg but he [C1] said he had already written one for 1mg lorazepam. The facility failed to provide routine and emergency drugs to Resident R1.10/29/25 1:45 PM- The findings were reviewed during

the exit conference with E1(NHA), E2 (DON), E3 (RDOCS), E4 (RN/UM) and E5 (RN/UM).

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Encore at West Meadow

255 Possum Park Road Newark, DE 19711

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 0760 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

received- Tasked [facility pharmacy] with notifying the facility for any new admission medication that requires a prescription and the prescription was not sent directly from the discharging facility- Educated staff members that the providers are to be informed immediately for a recognized failure in obtaining necessary medication- Educated the providers that prescriptions for medications from the Emergency supply box(E Box) must be written in the exact formulation of the drug supplied in the emergency supply box. The facility alleged that all these corrective actions were completed by 8/8/25 at 11:20 PM. The surveyor confirmed education with staff during interviews. 8/9/25 - Resident R1 was re-admitted to the facility after hospitalization. 8/11/25 - C1 (DO) documented in Resident R1's EMR re-admission History and Physical note- .

History of Present Illness- . The patient was readmitted there [hospital] with reported seizure-like activity.

There appeared to be some issues obtaining patient's chronic benzodiazepine therapy from the pharmacy

in a timely fashion at the time of admission. She apparently went 48 hours without a dose of her lorazepam therapy. Workup at the hospital was largely unremarkable and included EEG monitoring and MRI imaging.

She was evaluated by the neurology team who recommended ongoing benzodiazepine therapy without changes at this time.Diagnosis and Assessment: Seizure- appears to be related to benzodiazepine withdrawal.8/14/25 - C1 (DO) documented in Resident R1's EMR progress note, .Diagnosis and Assessment: Benzodiazepine dependence- secondary to prolonged use of high-dose lorazepam therapy, resulting in withdrawal seizure requiring hospitalization.10/29/25 9:45 AM - A review of Resident R1's MAR revealed the 8/5/25 8PM, 8/6/25 9 AM and 8/7/25 9 AM lorazepam doses were documented as not given/ see nurses notes.

The 8/6/25 8 PM lorazepam dose did not have any documentation in the MAR or progress notes regarding

this medication.10/29/25 10:39 AM - During an interview, E2 (DON) confirmed that Resident R1 did not receive any doses of lorazepam from 8/5/25 to 8/7/25. 10/29/25 1:45 PM- The findings were reviewed during the exit conference with E1(NHA), E2 (DON), E3 (RDOCS), E4 (RN/UM) and E5 (RN/UM).

Event ID:

Facility ID:

If continuation sheet