Pinnacle Rehabilitation & Health Center

F-F609

The facility policy Abuse, Neglect, Exploitation last updated, May 2024 indicated, . An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur .

Review of Resident R1's clinical record revealed:

1/2/25 - Resident R1 was admitted to the facility with diagnosis of Alzheimer's disease.

1/3/24 - A Brief Interview for Mental Status (BIMS) was completed for Resident R1 and showed a score of 8 out of 15 indicating that the resident was moderately cognitively impaired.

1/13/25 11:43 AM - During an interview E6 (LPN) stated that on 1/5/25, F1 reported that a staff was inappropriate to Resident R1. E6 stated that E8 (Supervisor) did not request that they write a statement.

1/13/25 11:57 AM - During an interview E7 (CNA) stated that on 1/5/25, F1 reported to her that a staff member was being mean to Resident R1. E7 further stated that Resident R1 had stated the staff was being rude. E7 reported

this to E8 (Supervisor) and stated that E8 did not interview them or have them write a statement.

1/13/25 12:56 PM - During an interview E8 stated that on 1/5/25, F1 reported to her that a staff member had said something to Resident R1 that was not nice. E8 had F1 write a statement and then placed the statement under

the door of E4 (SW) since it was the weekend. E8 stated that she checked the facility schedule on the alleged date/time of the incident and did not find an employee who matched the description.

1/13/25 1:16 PM - During an interview, E4 stated that they saw the statement in her office on 1/6/25 and gave it to E3 (ADON).

1/14/25 12:09 PM - During an interview E1 (NHA) stated they did not know about the statement written by F1, it was not brought forward as a formal matter and that Resident R1 was discharged the next day.

1/13/25 2:07 PM - During an interview, E1 (NHA) did not know about a statement made from F1 regarding Resident R1's accusation of abuse and that an investigation should have been completed.

There was no evidence that the facility investigated Resident R1's allegation of abuse to the state agency

1/14/25 12:55 PM - Findings were reviewed during the exit conference with E1 and E2 (DON).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 3 085020

F-F610

The facility policy titled Abuse, Neglect, Exploitation last updated, May 2024 indicated, .Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse .

Review of Resident R1's clinical record revealed:

1/2/25 - Resident R1 was admitted to the facility with a diagnosis including Alzheimer's disease.

1/3/24 - A Brief Interview for Mental Status (BIMS) was completed for Resident R1 and showed a score of 8 out of 15 indicating that the resident was moderately cognitively impaired.

1/13/25 11:57 AM - During an interview, E7 (CNA) stated that on 1/5/25 F1 reported to her that a staff member was being mean to Resident R1. E7 further stated that Resident R1 had stated that the staff was being rude.

1/13/25 12:56 PM - During an interview, E8 (Supervisor) stated that on 1/5/25 F1 reported to her that a staff member had said something to Resident R1 that was not nice. E8 had F1 write a statement and then placed the statement under the door of E4 (SW), since it was the weekend.

1/13/25 1:16 PM - During an interview, E4 stated that they saw the statement in her office on 1/6/25 and gave it to E3 (ADON).

1/13/25 1:56 PM - During an interview, E3 (ADON) did not know about a statement made from F1 regarding Resident R1's accusation of abuse.

1/13/25 2:07 PM - During an interview, E1 (NHA) did not know about a statement made from F1 regarding Resident R1's accusation of abuse.

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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 3 085020 Department of Health & Human Services Printed: 09/11/2025 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 085020 B. Wing 01/14/2025

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

Evergreen Post Acute 3034 South Dupont Blvd Smyrna, DE 19977

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 0609 There was no evidence that the facility reported Resident R1's allegation of abuse.

Level of Harm - Minimal harm or 1/14/25 12:55 PM - Findings were reviewed during the exit conference with E1 and E2 (DON). potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 3 085020 Department of Health & Human Services Printed: 09/11/2025 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 085020 B. Wing 01/14/2025

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

Evergreen Post Acute 3034 South Dupont Blvd Smyrna, DE 19977

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 0610 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or 47142 potential for actual harm Based on interview, record review and review of other facility documentation, it was determined that for one Residents Affected - Few (Resident R1) out of three sampled residents for investigating an allegation of abuse, the facility failed to protect residents from abuse and investigate an allegation of abuse. Findings include:

Cross refer to