Regency Healthcare & Rehab Center

F-F600

Review of Resident R43's clinical record revealed:

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

7/25/24 - Resident 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 - Resident R43 was care planned for behavior as evidenced by physical aggression and interventions included to administer meds as ordered.

11/7/24 - Resident 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 Resident R43's December 2024 MAR revealed that Resident 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, Resident 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 Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 16 085012 Department of Health & Human Services Printed: 09/09/2025 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 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

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 1/31/25 5:00 PM - Findings were discussed with E11 (NHA).

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

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 16 085012 Department of Health & Human Services Printed: 09/09/2025 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 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

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 40264

Residents Affected - Few Based on record review, observation and interview, it was determined that for one (Resident R43) out of three residents reviewed for bowel and bladder, the facility failed to evaluate Resident R43's decline in urinary continence and failed to maintain or restore continence after Resident R43's multiple falls related to his need for toileting assistance. Findings include:

Cross refer

F-F676

1. Resident R23's clinical record revealed:

11/8/24 - Resident R23 was admitted to the facility.

11/9/24 7:41 AM - Resident R23's admission evaluation documented:

. 8. Preferred Language: SPANISH

9. Do you need or want an interpreter to communicate with a doctor or health care staff? YES .

11/14/24 - The admission MDS assessment, under Section A, incorrectly documented that Resident R23's preferred language was English.

From 11/8/24 through 1/7/25, Resident R23 lacked a person-centered communication care plan as a Spanish-speaking resident.

1/8/25 - Two months after Resident R23 was admitted to the facility, a care plan was initiated for communication problem related to language barrier with an approach that included, but was not limited to, obtaining translation services.

1/13/25 - Resident R23 was discharged to home.

2/4/25 2:00 PM - During an interview, finding was reviewed with E1 (NHA).

2. Resident R89's clinical record revealed:

11/7/24 - Resident R89 was admitted to the facility.

11/8/24 - A care plan entitled, Resident to attends (sic) activities of choice until next progress note. The goal was Resident will attend group activities of choice until next review. Approaches were: escort to activity as needed; provide independent activity material as needed; provide monthly calendar; and remind resident of upcoming activities and/or event.

2/4/25 at 2:00 PM - During an interview, finding was reviewed with E1 (NHA).

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 16 085012 Department of Health & Human Services Printed: 09/09/2025 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 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

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 0656 40264

Level of Harm - Minimal harm or Cross refer

F-F684

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

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

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

7/25/24 - Resident 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 Resident R43 not to go to the bathroom without help (10/25/24).

7/31/24 - Resident R43's admission MDS assessment revealed that Resident 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) - Resident R43 was care planned for behaviors as evidenced by urinating on the floor and also defecating on the AC (air condition) unit. Resident R43's interventions included encouraging Resident R43 to call for assistance when he is ready to use the bathroom and providing Resident R43 with a urinal.

9/19/24 - Resident 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:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 16 085012 Department of Health & Human Services Printed: 09/09/2025 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 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

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 How long has the resident been incontinent - don't know

Level of Harm - Minimal harm or Has a trial of a toileting program attempted? No potential for actual harm Current toileting program or trial - No Residents Affected - Few Bowel - continent of stool - no

Is a toileting program currently being used .? - No

Program initiation: urinary TP - No .bowel TP - No

Do not initiate program, why? - (no answer)

10/2/24 - Resident R43's significant change MDS assessment revealed that Resident R43's cognition was moderately impaired and was frequently incontinent of urine and bowel. Resident R43 was not on a toileting program during the review period.

10/3/24 - A facility Bladder and Bowel Program Evaluation - Quarterly Assessment documented:

How long has the resident been incontinent - don't know

Has a trial of a toileting program attempted? Unable to determine

Current toileting program or trial - No

Bowel - continent of stool - no

Is a toileting program currently being used .? - No

Program initiation: urinary TP - No .bowel TP - No

Do not initiate program, why? - (no answer)

11/14/24 - Resident R43 was care planned for risk for skin break down as evidenced by incontinence and limited mobility with interventions including incontinent care after each incontinent episode.

1/2/25 - Resident R43's quarterly MDS assessment revealed that Resident R43's cognition was moderately impaired and was always continent of urine and occasionally incontinent of bowel during the review period.

1/3/24 - A facility Bladder and Bowel Program Evaluation - Quarterly Assessment documented:

How long has the resident been incontinent - N/A - continent

Has a trial of a toileting program attempted? No

Current toileting program or trial - No

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 16 085012 Department of Health & Human Services Printed: 09/09/2025 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 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

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 Bowel - continent of stool - yes

Level of Harm - Minimal harm or Is a toileting program currently being used .? - No potential for actual harm Program initiation: urinary TP (Toileting Program) - No .bowel TP - No Residents Affected - Few Do not initiate program, why? - continent of bladder and bowel

1/31/25 - A review of Resident R43's fall incident reports from August 2024 through December 2024 revealed the following:

- 8/13/24 11:40 PM - Resident was found sitting on the floor at the bathroom door with his feet facing his bed .

- 8/14/24 12:04 AM - Resident fell out of wheelchair onto his left side .Stated he was trying to take himself to

the bathroom .had recent fall related to toileting himself .

- 10/17/24 12:45 PM - Resident was transferring self from bed to go to the bathroom without asking for assistance, he fell before reaching to the bathroom, he reported hitting his head .was going to the bathroom fell and hit his head.

- 10/17/24 1:00 PM - Resident was found on the floor next to the bathroom in his room. Resident stated he was trying to use the bathroom and he fell . stated that he hit his head and he was nauseous .sent resident to hospital for further evaluation . Resident is being offered a commode and a medical review is underway due to resident frequent falls .Where Changes made to the care plan? Yes offer commode. Resident to be toileted via commode.

- 10/18/24 5:10 AM - Resident sitting on buttocks at the foot of the bed. I was trying to use the bathroom .

- 10/21/24 10:10 AM - Resident lying on the floor by the bathroom door trying to go to the bathroom.

1/30/25 9:31 AM - During an obsevation, Resident R43 was observed sitting on the bench in front of the nurse station while watching TV. E3 (ADON) and E4 (LPN/UM) were observed talking in the nurses station.

1/31/25 9:33 AM - In a follow up observation, Resident R43 stood up with unsteady gait, transferred self on the wheelchair and propelled his way to his room. Resident R43 parked his wheelchair outside the bathroom, stood up, entered the bathroom unassisted and unsupervised. The sound of the toilet flushed was heard. Resident R43 came out the bathroom and with unsteady gait turned to sit on the wheelchair. Resident R43 was seen self propelling back to the nurses station.

1/31/24 9:35 AM - During interview, E6 (LPN) stated that Resident R43 is continent of bowel and bladder and is able to go to the toilet but will still require staff supervision. E6 added that Resident R43 was a high fall risk and has impulsive and aggressive behaviors that could be harmful to himself, to the other residents or to the staff. We have to be careful when we are around him cause he gets agitated so easily and he is not compliant with asking for assistance when using the bathroom.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 16 085012 Department of Health & Human Services Printed: 09/09/2025 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 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

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 failed to evaluate Resident R43's toileting decline and initiate a personalized toileting program to address his falls while attempting to use the toilet. Level of Harm - Minimal harm or potential for actual harm 1/31/25 5:00 PM - Findings were discussed with E1 (NHA).

Residents Affected - Few 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).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 16 085012 Department of Health & Human Services Printed: 09/09/2025 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 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

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 0802 Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Level of Harm - Minimal harm or potential for actual harm 51625

Residents Affected - Some Based on observation and interview it was determined that the facility failed to ensure that a qualified person

in charge was present during all hours of operation. The presence of a certified food protection manager reduces the risk for a foodborne outbreak especially for vulnerable populations.

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).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 16 085012

F-F690 potential for actual harm 3. Review of Resident R43's clinical records revealed: Residents Affected - Some 9/19/24 - Resident 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 Resident R43's fall incident reports from August 2024 through December 2024 revealed that Resident 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 Resident R43's care plan lacked evidence that person centered care plan was developed to maintain or restore bladder and bowel continence after Resident 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 Resident 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 Resident R43's incontinence care plan initiated on 2/2/25.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 16 085012 Department of Health & Human Services Printed: 09/09/2025 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 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

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 40264 potential for actual harm Based on clinical record review and interview, it was determined that for one (Resident R43) out of one sampled Residents Affected - Some resident, the facility failed to ensure the physician's order to administer quetiapine fumarate (Seroquel) . Findings include:

Cross refer