Regency Healthcare & Rehab Center

(RM), E16 (VPO), E17 (DCS), E18 (Corp. IP/SD) and E19 (RN).

085012 02/04/2025

Regency Healthcare & Rehab Center 801 N.

Broom Street Wilmington, DE 19806

for services as needed.

for mood/behavior, the facility failed to coordinate with the PASRR program under Medicaid and refer

• R69's clinical record revealed:

12/17/24 - A PASRR Level 1 Screen was completed by the hospital and documented that R69 had no mental health diagnosis known or suspected and no current mental health medications prescribed. 12/27/24 - R69 was admitted to the facility. 1/13/25 - A psychiatric evaluation documented, . past psychiatric history of depression and anxiety . review of psychotropic med (medication) regimen and management of mood/behaviors .

Does endorse feelings of anxiousness intermittently .

Available records prior to facility admit reviewed and appreciated.

Reportedly w/ (with) lengthy psych history and diagnosis of anxiety as well as depression . noted h/o (history of) paranoia.

Resident was previously treated in the past with Olanzapine [antipsychotic] . 1/13/25 - A physician's order prescribed mirtazapine medication daily for R69's depression. 1/14/25 - A physician's order prescribed xanax medication two times a day and as needed for R69's anxiety. 1/15/25 - R69 was care planned for anxiety and depression with approaches that included, but were not limited to, administering medications as ordered. 1/29/25 - A psychiatric note documented, . seen today at request of facility staff due to worsening anxiety .

Recommendations: 1.

Continue mirtazapine . for depression . benefits greater than risks at this time. 2.

Continue xanax . for anxiety . 5.

Plan to contact out patient psych provider . for additional history/verification, may need to consider resume olanzapine/alternative AP [antipsychotic] as there is evidence of potential underlying psychotic process . 1/31/25 at 1:45 PM -

During an interview, E9 (SSD) was asked if he submitted a referral to the PASARR office to have a Level 1 screen completed for R69. E9 replied no. 2/4/25 at 3:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E15 (RM), E16 (VPO), E17 (DCS), E18 (Corp. IP/SD) and E19 (RN).

085012 02/04/2025

Regency Healthcare & Rehab Center 801 N.

Broom Street Wilmington, DE 19806

Review of R43's clinical records revealed: 9/19/24 - R43 was re-admitted to the facility with diagnoses including but not limited to dementia, bipolar disorder and insomnia due to mental disorder. 1/31/25 - A review of R43's fall incident reports from August 2024 through December 2024 revealed that R43 fell six (6) times related to his need for assistance with toileting on the following dates: - 8/13/24 11:40 PM; - 8/14/24 12:04 AM; - 10/17/24 12:45 PM; - 10/17/24 1:00 PM; - 10/18/24 5:10 AM and; - 10/21/24 10:10 AM. 1/31/25 - A review of R43's care plan lacked evidence that person centered care plan was developed to maintain or restore bladder and bowel continence after R43's multiple falls related to his need for toileting assistance. 1/31/25 5:00 PM - During interview, E1 (NHA) confirmed that an incontinence care plan was not developed for R43 and that the clinical team will be looking into it. 2/3/25 3:52 PM - In an email correspondence, E1 sent an attached file pertaining R43's incontinence care plan initiated on 2/2/25.

The facility failed to ensure R43's person centered care plan interventions and a personalized toileting program was reviewed to address R43's falls related to R43's need to use the bathroom. 2/4/25 at 3:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E15 (RM), E16 (VPO), E17 (DCS), E18 (Corp. IP/SD) and E19 (RN).

085012 02/04/2025

Regency Healthcare & Rehab Center 801 N.

Broom Street Wilmington, DE 19806

Review of R43's clinical record revealed: 7/24/24 - R43 was admitted to the facility with diagnoses including dementia. 7/25/24 - R43 was care planned for receiving antipsychotic medication (to help manage his aggressive behaviors) and is at risk for behaviors and side effects. 7/30/24 - R43 was care planned for behavior as evidenced by physical aggression and interventions included to administer meds as ordered. 11/7/24 - R43 had a physician's order for quetiapine fumarate (Seroquel) 50 mg give 1 tablet by mouth two times a day for bipolar disorder. 12/3/24 1:11 PM - A nurse progress noted documented, . quetiapine fumarate . med presently N/A (not available), reordered from pharmacy . 12/4/24 10:15 AM - A nurse progress note documented, . quetiapine fumarate . med not delivered from pharmacy despite being reordered.

Spoke to pharmacy and they stated that 'the claim was paid and it will be sent on our evening delivery'. will pass in rpeort . 12/4/24 1:37 PM - A nurse progress note documented, . quetiapine fumarate .awaiting delivery of med . 12/5/24 9:36 AM - A NP encounter note documented, .Of note, patient (sic) quetiapine (sic) 50 mg tablets not delivered by pharmacy and missed PM dose yesterday as well as AM and PM doses today, per nursing staff pharmacy reported to be delivered this evening.

Will plan to administer additional 50 mg doses at bedtime with routine 200 mg order . 1/31/25 12:34 PM - Review of R43's December 2024 MAR revealed that R43 missed three (3) doses of quetiapine fumarate 50 mg 1 tab on 12/3/24 at 2 pm.

The following day, 12/4/24, R43 missed two more doses at 8:00 AM and 2:00 PM, for a total of three missed doses. 1/31/25 2:40 PM - In an interview, E4 (LPN/UM) confirmed that R43's quetiapine fumarate 50 mg doses were not administered on 12/3/24 at 2:00 PM and on 12/4/24 at 8:00 AM and at 2:00 PM. 1/31/25 3:10 PM - During interview, E1 (NHA) confirmed that the physician was not notified right away on 12/3/24 when the quetiapine fumarate medication was not available. 1/31/25 5:00 PM - Findings were discussed with E11 (NHA). 2/4/25 at 3:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E15 (RM), E16 (VPO), E17 (DCS), E18 (Corp. IP/SD) and E19 (RN).

085012 02/04/2025

Regency Healthcare & Rehab Center 801 N.

Broom Street Wilmington, DE 19806

The facility failed to evaluate R43's toileting decline and initiate a personalized toileting program to address his falls while attempting to use the toilet. 1/31/25 5:00 PM - Findings were discussed with E1 (NHA). 2/4/25 at 3:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E15 (RM), E16 (VPO), E17 (DCS), E18 (Corp. IP/SD) and E19 (RN).

nutrition service.

person in charge was present during all hours of operation.

The presence of a certified food protection

CMS recognizes the U.S.

Food and Drug Administration's (FDA) Food Code and the Centers for Disease Control and Prevention's (CDC) food safety guidance as national standards to procure, store, prepare, distribute, and serve food in long term care facilities in a safe and sanitary manner. 1/29/25 11:00 AM -

Review of the kitchen staff work schedule provided by E23 (District Food Service Manager) revealed that only one staff person E22 (Food Service Manager) out of three (E22, E23 and E25) who possessed valid Food Protection Manager certificates from an Accredited Food Safety Program was scheduled to work from 12/1/24 through 12/28/24. E22 was scheduled to work seventeen days out of twenty-eight on the December 2024 kitchen staff schedule and eight days out of fourteen on the partial January 2025 schedule. E23 and E25 (Dietary) were not listed to work any days on the December 2024 or January 2025 kitchen staff schedule. 2/4/25 at 3:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E15 (RM), E16 (VPO), E17 (DCS), E18 (Corp. IP/SD) and E19 (RN).

085012 02/04/2025

Regency Healthcare & Rehab Center 801 N.

Broom Street Wilmington, DE 19806

Review of R43's clinical record revealed:

7/24/24 - R43 was admitted to the facility with diagnoses including dementia.

7/25/24 - R43 was care planned for receiving antipsychotic medication (to help manage his aggressive behaviors) and is at risk for behaviors and side effects.

7/30/24 - R43 was care planned for behavior as evidenced by physical aggression and interventions included to administer meds as ordered.

11/7/24 - R43 had a physician's order for quetiapine fumarate (Seroquel) 50 mg give 1 tablet by mouth two times a day for bipolar disorder.

12/3/24 1:11 PM - A nurse progress noted documented, . quetiapine fumarate . med presently N/A (not available), reordered from pharmacy .

12/4/24 10:15 AM - A nurse progress note documented, . quetiapine fumarate . med not delivered from pharmacy despite being reordered.

Spoke to pharmacy and they stated that 'the claim was paid and it will be sent on our evening delivery'. will pass in rpeort .

12/4/24 1:37 PM - A nurse progress note documented, . quetiapine fumarate .awaiting delivery of med .

12/5/24 9:36 AM - A NP encounter note documented, .Of note, patient (sic) quetiapine (sic) 50 mg tablets not delivered by pharmacy and missed PM dose yesterday as well as AM and PM doses today, per nursing staff pharmacy reported to be delivered this evening.

Will plan to administer additional 50 mg doses at bedtime with routine 200 mg order .

1/31/25 12:34 PM - Review of R43's December 2024 MAR revealed that R43 missed three (3) doses of quetiapine fumarate 50 mg 1 tab on 12/3/24 at 2 pm.

The following day, 12/4/24, R43 missed two more doses at 8:00 AM and 2:00 PM, for a total of three missed doses.

1/31/25 2:40 PM - In an interview, E4 (LPN/UM) confirmed that R43's quetiapine fumarate 50 mg doses were not administered on 12/3/24 at 2:00 PM and on 12/4/24 at 8:00 AM and at 2:00 PM.

1/31/25 3:10 PM - During interview, E1 (NHA) confirmed that the physician was not notified right away on 12/3/24 when the quetiapine fumarate medication was not available.

085012

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 085012 B.

Wing 02/04/2025

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

Regency Healthcare & Rehab Center 801 N.

Broom Street Wilmington, DE 19806

The facility failed to develop and implement a person-centered activity care plan for R89 that included measurable objectives and timeframes to meet R89's medical, mental and psychosocial needs.

085012

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 085012 B.

Wing 02/04/2025

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

Regency Healthcare & Rehab Center 801 N.

Broom Street Wilmington, DE 19806

A review of R43's clinical records revealed the following:

7/24/24 - R43 was admitted to the facility with diagnoses including but not limited to dementia.

7/25/24 - R43 was care planned for ADL (Activities of Daily Living) deficit related cognition with interventions including assisting R43 to attend activities of choice. In addition, R43 was set up for care and supervise/verbal dues (sic) to assure he follow thru.

7/25/24 - R43 was care planned for falls related to .poor safety awareness .with interventions including offering toileting before going to bed (8/14/24) and reminding R43 not to go to the bathroom without help (10/25/24).

7/31/24 - R43's admission MDS assessment revealed that R43's cognition was severely impaired and was always continent of urine and bowel during the review period.

9/6/24 (revised 1/22/25) - R43 was care planned for behaviors as evidenced by urinating on the floor and also defecating on the AC (air condition) unit. R43's interventions included encouraging R43 to call for assistance when he is ready to use the bathroom and providing R43 with a urinal.

9/19/24 - R43 was readmitted from the psych hospital from 9/6/24 through 9/19/24

9/19/24 - A facility Bladder and Bowel Continence Evaluation - Readmission Assessment documented:

Is resident completely continent? - No

Functional Mobility, Manual Dexterity, Toileting Ability - Extensive Assist

Bowel Continence - Occasional

Bladder Continence - Occasional

Resident toileting preference - Brief

List any further important details - none

9/25/24 - a facility Bladder and Bowel Program Evaluation - Quarterly Assessment documented:

085012

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 085012 B.

Wing 02/04/2025

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

Regency Healthcare & Rehab Center 801 N.

Broom Street Wilmington, DE 19806

Review of R43's clinical records revealed:

9/19/24 - R43 was readmitted to the facility with diagnoses including but not limited to dementia, bipolar disorder and insomnia due to mental disorder.

1/31/25 - A review of R43's fall incident reports from August 2024 through December 2024 revealed that R43 fell six (6) times related to his need for assistance with toileting on the following dates:

- 8/13/24 11:40 PM;

- 8/14/24 12:04 AM;

- 10/17/24 12:45 PM;

- 10/17/24 1:00 PM;

- 10/18/24 5:10 AM and;

- 10/21/24 10:10 AM.

1/31/25 - A review of R43's care plan lacked evidence that person centered care plan was developed to maintain or restore bladder and bowel continence after R43's multiple falls related to his need for toileting assistance.

1/31/25 5:00 PM - During interview, E1 (NHA) confirmed that an incontinence care plan was not developed for R43 and that the clinical team will be looking into it.

2/3/25 3:52 PM - In an email correspondence, E1 sent an attached file pertaining R43's incontinence care plan initiated on 2/2/25.

The facility failed to ensure R43's person centered care plan interventions and a personalized toileting program was reviewed to address R43's falls related to R43's need to use the bathroom.

2/4/25 at 3:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E15 (RM), E16 (VPO), E17 (DCS), E18 (Corp. IP/SD) and E19 (RN).

085012

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 085012 B.

Wing 02/04/2025

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

Regency Healthcare & Rehab Center 801 N.

Broom Street Wilmington, DE 19806