Inspection Reports for
Delaware Highlands Assisted Living

The resurvey included attached complaints 198046, 193817, and 192162.

The administrator failed to ensure licensed staff placed residents' full names on original packages of over-the-counter medications. Additionally, dietary staff failed to document food temperatures as required, with missing logs for January and early February 2026.

The complaint investigations involved multiple allegations including failure to notify physicians and family members of significant resident changes, failure to protect a resident from elopement and neglect, failure to report abuse/neglect allegations timely, and failure to properly document resident care and incidents. The findings substantiated these allegations.

The facility failed to notify physicians and family members about significant resident changes, failed to protect a cognitively impaired resident from elopement resulting in immediate jeopardy, failed to report abuse/neglect allegations timely, and failed to accurately document functional capacity, negotiated service agreements, wound care, and incident reports.

All previously cited deficiencies were corrected as of the revisit date. The report lists multiple regulatory provisions with completed corrections.

This inspection was complaint-driven, involving multiple complaint numbers as listed in the initial comments section.

The facility failed to protect residents from neglect, failed to complete required Functional Capacity Screens (FCS) following significant changes or annually, failed to maintain accurate and updated Negotiated Service Agreements (NSA) reflecting residents' needs, failed to ensure medication administration was properly supervised, and failed to document incidents and follow-up actions in resident records.

The survey included attached complaints #156316, 154588, 151356, 151260, 143199, 139072, and 150645.

The facility failed to ensure proper medication storage according to manufacturer and regulatory requirements, maintain complete employee records including timely background and registry checks, and comply with tuberculosis screening guidelines for staff.

All previously cited deficiencies listed with regulation numbers were corrected as of the revisit date. The report confirms completion of corrective actions for multiple cited regulations.

The visit was triggered by complaints regarding delayed staff response to resident call lights. Interviews and record reviews confirmed long response times, sometimes up to 39 minutes, and substantiated the complaint.

The administrator failed to ensure the provision or coordination of the range of services specified in each resident's negotiated service agreement, including timely response to resident requests for assistance. Staff response times to call lights were frequently longer than the required 16 minutes, with 17 instances of delayed responses over two days.

The inspection found multiple deficiencies including failure to complete negotiated service agreements in collaboration with residents or their representatives, failure to ensure licensed nurses provide or coordinate necessary health care services, improper delegation of nursing procedures, medication administration errors, and improper medication storage.

The report confirms that the previously cited deficiency under regulation 26-41-104 (d) was corrected as of 06/05/2017. No other deficiencies are listed.

The report confirms that the previously reported deficiency under regulation 26-41-104(d) was corrected as of the revisit date.

Complaint #110145 was investigated during the licensure resurvey.

The facility failed to accurately complete functional capacity screens for residents, ensure health care services met standards, properly assess self-administration of medications, and administer medications according to provider orders. Additionally, documentation of incidents was incomplete and the facility failed to conduct required emergency evacuation drills.

The survey identified deficiencies including failure to notify physicians of resident accidents with potential injury, failure to report allegations of abuse to the department within required timeframes, and failure to administer medications, specifically insulin, according to physician orders.

The visit included complaint investigations with multiple complaint numbers cited, indicating concerns about medication administration and resident record maintenance.

The facility failed to ensure medications were administered according to physician orders and professional standards, with discrepancies in narcotic medication records. Additionally, the facility failed to maintain resident records properly, including vital signs documentation lacking signatures, dates, and follow-up on abnormal findings.

The complaint investigation involved allegations of neglect related to resident #124 wandering outside the facility unsupervised on 5-24-14 and 5-26-14, which were not reported to the department within 24 hours as required.

The facility failed to report an allegation of neglect involving resident #124 within 24 hours and failed to ensure food was prepared and served at proper temperatures with safe methods. Food temperature logs lacked documentation for multiple dates in August 2014, and the facility lacked a policy for monitoring food temperatures.