Inspection Report Summary
The most recent inspection on November 18, 2025 found no deficiencies during an unannounced complaint investigation. Earlier inspections showed a pattern of deficiencies related to resident safety, abuse prevention, call light accessibility, food safety, and emergency preparedness. Complaint investigations substantiated issues including inadequate supervision leading to resident injury, failure to prevent and report abuse, and staffing shortages, with one immediate jeopardy finding during a COVID-19 outbreak that was later abated. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows some improvement over time, with the latest survey indicating compliance after previous citations.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
15.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
73% worse than Delaware average
Delaware average: 8.8 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
101 residents
Based on a November 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 0
Nov 18, 2025
Visit Reason
An unannounced Complaint Survey was conducted at the facility from November 18, 2025 through November 20, 2025.
Findings
No deficient practice was identified during the survey.
Complaint Details
The complaint investigation was unannounced and no deficiencies were found, indicating no substantiated deficient practice.
Report Facts
Survey sample residents: 12
Inspection Report
Annual Inspection
Deficiencies: 8
Dec 12, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, abuse prevention, safety, food service, and call system functionality.
Findings
The facility was found deficient in multiple areas including failure to ensure call light accessibility for residents, inadequate prevention and reporting of resident-to-resident abuse, improper investigation of abuse allegations, unsafe bed mattress fit creating accident hazards, failure to enforce food service safety standards including beard guard use and food storage, and lack of a working call system in one resident's bathroom.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to ensure one resident had call light accessible for use, creating potential for unmet needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to have a policy on call lights. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to protect residents from resident-to-resident abuse in two separate incidents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely report suspected resident-to-resident abuse to the State Agency within two hours. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to complete a thorough investigation of an allegation of abuse involving a Certified Nurse Aide. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure a mattress fit the bed frame, creating a gap that posed an accident hazard to a resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure beard guards were worn during food production and failure to properly store and date food items, risking physical contamination. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure a working call system or alternative call device was available in a resident's bathroom and bathing area. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for call light accessibility: 29
Residents reviewed for abuse: 6
Residents affected by food safety deficiencies: 109
Gap between mattress and footboard: 11
Gap between mattress and footboard: 6
Number of peeled hard-boiled eggs undated: 20
Frozen chicken cutlets undated: 32
Frozen hamburger patties undated: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN1) | Confirmed call light accessibility issue for resident R39. | |
| Certified Nurse Aide (CNA3) | Acknowledged call light was under resident's bed and later stated checking for doorbell. | |
| Director of Nurses (DON) | Director of Nursing | Confirmed call light accessibility policy, reported abuse incident late, and stated investigation deficiencies. |
| Nurse Consultant (NC2) | Stated no policy on call lights. | |
| Registered Nurse 2 (RN) | Commented on residents' agitation and redirection. | |
| Administrator | Observed mattress gap, call light system failure, and food safety issues. | |
| Dietary Aide (DA)2 | Observed not wearing beard guard during food preparation. | |
| Dietary Aide (DA)3 | Observed not wearing beard guard during food preparation. | |
| Food Service Director (FSD) | Confirmed beard guard policy and food safety deficiencies. |
Inspection Report
Annual Inspection
Deficiencies: 7
Dec 12, 2024
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements related to resident care, abuse prevention, safety, food service, and call system functionality.
Findings
The facility was found deficient in multiple areas including failure to ensure call light accessibility for residents, inadequate prevention and reporting of resident-to-resident abuse, improper investigation of abuse allegations, unsafe bed mattress fit creating accident hazards, failure to enforce food service safety standards including beard guard use and food storage, and lack of a working call system in a resident's bathroom.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure one of 29 residents had their call light accessible for use, creating potential for unmet needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure two of six residents reviewed were free from resident-to-resident abuse for two separate incidents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely report suspected resident-to-resident abuse to the State Agency within two hours for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to complete a thorough investigation of an allegation of abuse for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure one resident had a mattress that fit the bed frame, creating potential for injury. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure beard guards were worn during food production and failure to store food in accordance with professional standards, risking physical contamination. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure one resident had an alternative call light device available when the call light system malfunctioned, risking unmet care needs. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for call light accessibility: 29
Residents reviewed for abuse: 6
Residents affected by call light accessibility deficiency: 1
Residents affected by resident-to-resident abuse deficiency: 2
Residents affected by delayed abuse reporting: 1
Residents affected by incomplete abuse investigation: 1
Residents affected by mattress fit deficiency: 1
Residents affected by food safety deficiencies: 109
Residents affected by call system malfunction: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN1) | Confirmed call light accessibility issue for Resident R39 | |
| Certified Nurse Aide (CNA3) | Acknowledged call light was under bed for Resident R39 and later stated checking for doorbell | |
| Director of Nurses (DON) | Director of Nursing | Confirmed call light accessibility responsibility, acknowledged abuse incidents and reporting failures, and noted need for mattress bolster |
| Nurse Consultant (NC2) | Stated no policy on call lights | |
| Registered Nurse 2 (RN) | Commented on residents' agitation and redirection | |
| Administrator | Observed mattress gap and call light system failure, acknowledged reporting delays | |
| Certified Nurse Aide (CNA9) | Alleged to have been rough with resident during care | |
| Food Service Director (FSD) | Noted beard guard policy and food safety lapses | |
| Dietary Aide (DA)2 | Observed not wearing beard guard | |
| Dietary Aide (DA)3 | Observed not wearing beard guard | |
| Certified Nurse Aide (CNA3) | Stated checking for doorbell in resident rooms |
Inspection Report
Recertification And Complaint Investigation
Census: 109
Deficiencies: 7
Dec 12, 2024
Visit Reason
A Recertification and Complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Delaware, Department of Health and Social Services, Division of Health Care Quality from 12/09/24 to 12/12/24.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified related to call light accessibility, freedom from abuse and neglect, reporting of alleged violations, accident hazards, food safety, and resident call system functionality.
Complaint Details
The complaint investigation revealed failures related to resident-to-resident abuse reporting and investigation, as well as ensuring residents were free from abuse and neglect. The allegations were reported to Delaware Healthcare (DHCQ) upon becoming aware.
Severity Breakdown
SS=D: 6
SS=F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure one resident had call light accessible for use creating potential unmet needs. | SS=D |
| Failure to ensure residents were free from abuse, neglect, misappropriation, and exploitation. | SS=D |
| Failure to report an incident of resident-to-resident abuse to the State Agency within required timeframes. | SS=D |
| Failure to investigate allegations of abuse thoroughly. | SS=D |
| Failure to ensure one resident environment remained free of accident hazards (mattress not fitting bed frame). | SS=D |
| Failure to ensure beard guards were worn during food production and failure to store food properly. | SS=F |
| Failure to ensure residents had accessible call bell devices; call light system malfunctioned. | SS=D |
Report Facts
Survey Dates: 12/09/24 to 12/12/24
Census: 109
Sample Size: 29
Deficiencies cited: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Confirmed CNAs were to ensure call light accessibility; conducted audits and education related to call bell placement and abuse reporting. |
| Certified Nurse Aide 9 | Certified Nurse Aide (CNA) | Involved in investigation of abuse allegations and was suspended pending investigation. |
| Registered Nurse 2 | Registered Nurse (RN) | Provided statements regarding resident agitation and redirection. |
| Food Service Director | Food Service Director (FSD) | Provided information on food safety practices and audits. |
| Dietary Aide 2 | Dietary Aide (DA) | Observed not wearing beard nets during food preparation. |
| Dietary Aide 3 | Dietary Aide (DA) | Observed not wearing beard nets during food preparation. |
Inspection Report
Annual Inspection
Deficiencies: 1
Jul 16, 2024
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with regulations, focusing on accident prevention and resident safety.
Findings
The facility failed to provide adequate supervision to prevent an accident involving one resident (R1) who rolled out of bed, fell three feet, sustained a head laceration, and required emergency hospitalization. The facility recognized the seriousness of the incident, conducted an investigation, implemented corrective actions, and regained compliance by 6/14/24.
Severity Breakdown
Level of Harm - Actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision to prevent an accident resulting in a resident falling out of bed and sustaining a head injury. | Level of Harm - Actual harm |
Report Facts
Residents affected: 1
Distance of fall: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E6 | CNA | Staff member who lost grip on resident R1 causing the fall |
| E5 | LPN | Nurse who documented the fall and resident condition |
| E2 | Director of Nursing (DON) | Interviewed regarding facility response to the incident |
| E3 | Chief Nursing Officer (CNO) | Interviewed regarding facility response to the incident |
| E1 | Participated in findings review | |
| E10 | Chief Operating Officer (COO) | Participated in findings review |
| E11 | Corporate Nurse | Participated in findings review |
| E12 | Corporate Nurse | Participated in findings review |
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 1
Jul 16, 2024
Visit Reason
An unannounced complaint survey was conducted at the facility from July 12, 2024, through July 16, 2024, based on interviews, record review, and other facility documentation.
Findings
The facility failed to provide adequate supervision to prevent an accident involving a totally dependent resident who fell out of bed and sustained a head injury. The facility recognized the seriousness of the incident and took corrective actions, resulting in regaining compliance on July 14, 2024.
Complaint Details
The complaint investigation was substantiated as the facility failed to prevent an accident for one resident (R1) who was totally dependent and fell out of bed, resulting in harm. The facility conducted a root cause analysis, staff education, and monitoring to address the deficient practice.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility failed to provide adequate supervision to prevent an accident where a resident rolled out of bed, fell three feet, sustained a head laceration, and required emergency hospital transfer. | SS=G |
Report Facts
Survey sample size: 3
Resident census: 105
Inspection Report
Annual Inspection
Deficiencies: 5
Nov 8, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, quality of care, medication management, and dental services at Cadia Rehabilitation Capitol nursing home.
Findings
The facility was found deficient in accurately completing resident assessments, revising care plans to reflect current needs, following physician orders, implementing gradual dose reductions for psychotropic medications, and providing routine dental services to residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to accurately complete MDS assessments to reflect resident status for two residents (R98 and R417). | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure care plans were revised to reflect current care needs and lacked required interdisciplinary team members at care plan meetings for four residents (R7, R20, R56, and R87). | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to follow physician orders for two residents (R58 and R87), including lack of one-to-one supervision and failure to get resident out of bed for lunch daily. | Level of Harm - Minimal harm or potential for actual harm |
| Facility lacked evidence of gradual dose reduction and proper diagnosis for psychotropic medication prescribed to resident R58. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to assist four residents (R5, R39, R40, and R66) in obtaining routine dental services and lacked evidence of annual dental assessments. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for resident assessment: 29
Residents reviewed for care plans: 29
Residents reviewed for quality of care: 29
Residents reviewed for unnecessary medications: 6
Residents sampled for dental services: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E3 | Chief Nursing Officer (CNO) | Confirmed inaccuracies in assessments, care plan issues, lack of one-to-one supervision, medication discrepancies, and dental service deficiencies. |
| E1 | Nursing Home Administrator (NHA) | Participated in exit conferences reviewing findings. |
| E2 | Director of Nursing (DON) | Participated in exit conferences reviewing findings. |
| E4 | Chief Operating Officer (COO) | Participated in exit conferences reviewing findings. |
| E7 | Social Worker (SW) | Described dental appointment scheduling process and confirmed lack of annual dental assessments. |
| E15 | Certified Nursing Assistant (CNA) | Confirmed lack of awareness of physician orders for resident care. |
| E16 | Utilization Manager (UM) | Confirmed nurses transcribe orders and update CNA flow sheets. |
| E24 | Registered Nurse, Utilization Manager (RN, UM) | Confirmed medication use and diagnosis discrepancies. |
| E23 | Psychiatric Nurse Practitioner (PNP) | Confirmed diagnosis discrepancies for prescribed medication. |
Inspection Report
Annual Inspection
Deficiencies: 15
Nov 8, 2023
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found to have multiple deficiencies including failure to ensure resident dignity, inaccurate resident assessments, incomplete care plans, failure to follow physician orders, inadequate dental services, improper food handling, inaccurate medical records, and lack of an infection prevention and control program.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 15
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to ensure care was provided in a way that promoted dignity and respect for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to accurately complete MDS assessments to reflect resident status for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to coordinate assessments with the pre-admission screening and resident review program and referring for services as needed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement a complete care plan that meets all the resident's needs for three residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop the complete care plan within 7 days of the comprehensive assessment and ensure required interdisciplinary team members were present for care plan meetings for four residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide care and assistance to perform activities of daily living for one resident, including grooming needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide activities to meet resident's needs for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate treatment and care according to physician orders for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate care for a resident to maintain and/or improve range of motion and mobility for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide routine and 24-hour emergency dental care for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide or obtain dental services for four residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to procure food from approved sources, maintain sanitary food storage and preparation areas, and maintain food temperature logs. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to safeguard resident-identifiable information and maintain accurate medical records for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide and implement an infection prevention and control program including a comprehensive water management plan to prevent Legionella growth. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure one staff member received annual abuse training timely. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for resident assessment: 29
Residents reviewed for care plans: 29
Meals reviewed for temperature logs: 276
Meals missed menu choices: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E18 | COTA | Staff member overdue for annual abuse training. |
| E3 | Chief Nursing Officer (CNO) | Confirmed multiple deficiencies including inaccurate assessments, lack of dental services, and failure to follow physician orders. |
| E7 | Social Worker (SW) | Responsible for coordinating dental appointments and PASARR referrals. |
| E8 | Food Service Director | Confirmed issues with menu delivery and food temperature logs. |
| E13 | Unit Manager (UM) | Confirmed splint not applied but signed off as done. |
| E15 | Certified Nursing Assistant (CNA) | Confirmed failure to follow care plan for resident grooming and getting out of bed for lunch. |
Inspection Report
Annual Inspection
Census: 107
Deficiencies: 17
Nov 8, 2023
Visit Reason
An unannounced annual, complaint and extended survey was conducted at the facility from October 30, 2023 through November 8, 2023, including an Emergency Preparedness survey.
Findings
The survey identified multiple deficiencies related to emergency preparedness training, resident rights, accuracy of assessments, comprehensive care planning, quality of care, infection control, and abuse prevention. The facility failed to ensure staff training, proper documentation, and resident care compliance in several areas.
Severity Breakdown
SS=D: 1
SS=E: 4
Deficiencies (17)
| Description | Severity |
|---|---|
| Facility failed to provide emergency preparedness training to one staff member within the past year. | — |
| Facility failed to ensure care was provided in a way that promoted dignity and respect for one resident. | SS=D |
| Facility failed to accurately complete MDS assessments for two residents. | — |
| Facility failed to ensure a referral for PASARR screening was completed for four residents. | — |
| Facility failed to develop and implement comprehensive person-centered care plans for three residents. | — |
| Facility failed to ensure care plans were revised to reflect current care needs for four residents. | — |
| Facility failed to ensure care plans included physician and nurse aide participation for four residents. | — |
| Facility failed to ensure ADL care for one resident was provided to maintain good grooming. | — |
| Facility failed to ensure residents received routine and emergency dental services. | SS=E |
| Facility failed to ensure residents received proper food preferences and choices. | — |
| Facility failed to ensure food safety requirements were met including proper food storage and temperature logs. | SS=E |
| Facility failed to ensure residents received proper 1:1 supervision as ordered. | — |
| Facility failed to ensure residents received proper care related to splints and skin integrity. | — |
| Facility failed to ensure residents received proper care related to mobility and use of splints. | — |
| Facility failed to ensure residents received proper care related to psychotropic drug use and PRN orders. | — |
| Facility failed to ensure infection prevention and control program was fully implemented. | SS=E |
| Facility failed to ensure staff received annual abuse training and failed to protect residents from abuse. | — |
Report Facts
Facility census: 107
Survey sample size: 29
Staff sampled for abuse training: 12
Residents reviewed for care plans: 29
Residents reviewed for dental services: 6
Meals reviewed: 276
Inspection Report
Annual Inspection
Deficiencies: 11
Mar 29, 2022
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements for nursing home care, including resident dignity, abuse prevention, hospitalization notifications, PASARR screening, activities of daily living assistance, pressure ulcer care, medication management, food safety, immunizations, and COVID-19 vaccination documentation.
Findings
The facility was found deficient in multiple areas including failure to provide dignity for a resident with a urinary catheter, failure to prevent sexual abuse, failure to notify ombudsman and provide bed-hold notices upon hospitalization, lack of PASARR screening for admission, inadequate assistance with activities of daily living, delayed treatment of a pressure ulcer, inadequate monitoring and indication for psychotropic medications, food service safety violations, failure to document immunization offers or declinations, and failure to document COVID-19 vaccine offers or declinations.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to provide dignity for a resident with a urinary catheter by not covering the catheter bag initially. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure one resident was free from sexual abuse by another resident despite behavioral disturbances and lack of adequate supervision. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify the ombudsman of resident transfers to the hospital for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide bed-hold notice to resident representatives upon transfer to hospital for three residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to have a PASARR screening on admission from the State authority for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to assist one resident with shaving and transferring out of bed as required. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to initiate timely treatment for a pressure ulcer behind a resident's ear. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to have adequate indication for use and monitoring of psychotropic medications for one resident, including lack of baseline AIMS assessment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store, prepare, distribute and serve food in accordance with professional standards, including obstructed hand washing station and improper padding in walk-in refrigerator. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide evidence that influenza and pneumococcal immunizations were offered or declined for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide evidence that COVID-19 vaccines were offered or declined for two residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled for abuse: 4
Residents sampled for hospitalization: 4
Residents sampled for hospitalization: 4
Residents sampled for PASARR: 2
Residents sampled for ADL assistance: 5
Residents sampled for pressure ulcers: 3
Residents sampled for unnecessary medications: 6
Residents sampled for immunizations: 5
Residents sampled for COVID-19 immunizations: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E8 | CNA | Interviewed about catheter bag cover |
| E4 | Unit Manager | Confirmed catheter bag privacy cover requirement and commented on resident assistance |
| E1 | NHA | Participated in exit conferences reviewing findings |
| E2 | DON | Participated in exit conferences and confirmed findings |
| E3 | Regional CNO | Participated in exit conferences and confirmed findings |
| E12 | RN | Documented behavior notes and confirmed abuse findings |
| E14 | NP | Documented physician progress notes related to behavioral disturbances |
| E11 | RN | Documented nurse notes and confirmed abuse findings |
| E10 | UM | Confirmed delayed treatment for pressure ulcer |
| E6 | SW | Reviewed absence of PASARR screening |
Inspection Report
Annual Inspection
Census: 105
Deficiencies: 11
Mar 29, 2022
Visit Reason
An unannounced annual and complaint survey was conducted at the facility from March 22, 2022 through March 29, 2022 to assess compliance with regulatory requirements.
Findings
The survey included observations, interviews, and clinical record reviews. Deficiencies were identified related to personal privacy, abuse prevention, transfer notices, PASARR screening, ADL care, skin integrity, psychotropic medication use, food safety, immunizations, and COVID-19 vaccination policies.
Complaint Details
The survey included complaint investigation related to abuse and neglect. It was substantiated that the facility failed to ensure residents were free from sexual abuse and failed to protect resident dignity.
Severity Breakdown
F 583 SS=D: 1
F 600 SS=D: 1
F 623 SS=D: 1
F 625 SS=D: 1
F 645 SS=D: 1
F 677 SS=D: 1
F 686 SS=D: 1
F 758 SS=D: 1
F 812 SS=D: 1
F 883 SS=D: 1
F 887 SS=D: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to provide dignity for a resident with a urinary catheter by not covering catheter drainage bags. | F 583 SS=D |
| Facility failed to ensure residents were free from sexual abuse. | F 600 SS=D |
| Facility failed to notify the ombudsman of resident transfers to hospital. | F 623 SS=D |
| Facility failed to provide required notices regarding bed hold policy upon transfer to hospital. | F 625 SS=D |
| Facility failed to have a PASARR screening for admission from the State authority. | F 645 SS=D |
| Facility failed to provide adequate ADL care including assistance with shaving and transferring. | F 677 SS=D |
| Facility failed to initiate treatment for pressure ulcers in a timely manner. | F 686 SS=D |
| Facility failed to ensure psychotropic drugs were properly monitored and documented. | F 758 SS=D |
| Facility failed to ensure food safety requirements including handwashing and food storage. | F 812 SS=D |
| Facility failed to provide evidence of influenza and pneumococcal immunizations for residents. | F 883 SS=D |
| Facility failed to ensure COVID-19 vaccination policies were followed and documented. | F 887 SS=D |
Report Facts
Facility census: 105
Survey sample: 38
Deficiencies cited: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E8 | Certified Nursing Assistant (CNA) | Interviewed regarding catheter bag coverage. |
| E4 | Unit Manager | Confirmed catheter drainage bags should be covered. |
| E1 | Nursing Home Administrator (NHA) | Participated in exit conference and review of findings. |
| E2 | Director of Nursing (DON) | Participated in exit conference and review of findings. |
| E3 | Regional Chief Nursing Officer (CNO) | Participated in exit conference and review of findings. |
| E12 | Registered Nurse (RN) | Interviewed regarding resident behaviors. |
| E14 | Nurse Practitioner (NP) | Provided psychiatric consult and progress notes. |
| E15 | Nurse Practitioner (NP) | Notified and ordered psychotropic medication adjustments. |
| E10 | Unit Manager (UM) | Confirmed clinical record findings related to skin trauma. |
| E7 | Licensed Practical Nurse (LPN) | Documented resident complaint of pain. |
| E6 | Social Worker (SW) | Interviewed regarding PASARR screening absence. |
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 1
Aug 26, 2021
Visit Reason
An unannounced COVID-19 Focused Infection Control Survey and Complaint Survey was conducted by the State of Delaware Division of Health Care Quality from August 24, 2021 through August 26, 2021.
Findings
The facility was found to be in compliance with CDC recommended practices for COVID-19 preparation and infection control. However, a staffing deficiency was identified related to failure to maintain the minimum required direct care hours per resident per day (PPD) of 3.28 during the review period.
Complaint Details
The complaint investigation revealed that for two out of 14 days reviewed, the facility failed to provide the required staffing level of at least 3.28 hours of direct care per resident per day. The facility was found out of compliance with Delaware Code Chapter 11 Nursing Facilities and Similar Facilities.
Deficiencies (1)
| Description |
|---|
| The facility failed to maintain the minimum PPD staffing requirement of 3.28 hours of direct care per resident per day as evidenced by staffing worksheets showing PPD of 3.20 on 8/8/21 and 8/22/21. |
Report Facts
Facility census: 99
Survey sample size: 8
Direct care hours per resident per day (PPD): 3.28
Direct care hours per resident per day (PPD): 3.2
Days reviewed: 14
Days out of compliance: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Frank Aksoy | Administrator | Signed staffing worksheets and survey documents |
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 2
Nov 20, 2020
Visit Reason
An unannounced COVID-19 Focused Infection Control and Complaint Survey was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection, beginning November 13, 2020 and ending November 20, 2020.
Findings
The facility failed to follow CDC's recommendations during a COVID-19 outbreak for one resident, including failure to ensure adherence to isolation precautions and infection control practices. The facility also failed to maintain minimum staffing levels and proper employee screening for COVID-19 symptoms.
Complaint Details
The survey was complaint-related and focused on infection control practices during a COVID-19 outbreak. Immediate jeopardy was identified and abated. The complaint was substantiated based on observations, interviews, and record reviews.
Deficiencies (2)
| Description |
|---|
| Failure to follow CDC's recommendations during a COVID-19 outbreak for one resident, including failure to ensure adherence to isolation precautions. |
| Failure to maintain minimum staffing levels required by Delaware Code Chapter 11 Nursing Facilities and Similar Facilities. |
Report Facts
Facility census: 95
Survey sample size: 6
Minimum staffing hours: 3.28
Staffing hours provided: 2.91
Staffing audit period: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Hupp | Director of Nursing | Named in the plan of correction and staffing findings. |
| Michael Junetta | Chief Nursing Officer | Signed the state survey report related to staffing deficiencies. |
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 5
Jan 7, 2020
Visit Reason
An unannounced complaint survey was conducted at the facility from January 7, 2020 through January 10, 2020 to investigate allegations of neglect and other concerns.
Findings
The facility was found to have multiple deficiencies related to quality of care, skin integrity, pain management, drug regimen review, and psychotropic drug use. Specific failures included inadequate neurological assessments, failure to prevent and treat pressure ulcers, failure to manage pain appropriately, and failure to properly review and monitor medications.
Complaint Details
The visit was triggered by a complaint alleging neglect and failure to provide appropriate care. The complaint was substantiated based on findings related to neurological assessments, pressure ulcer prevention and treatment, pain management, and medication oversight.
Severity Breakdown
Level D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to conduct neurological assessments as ordered for one resident, resulting in increased risk for bleeding in the brain. | Level D |
| Failure to implement care and services to prevent and heal pressure ulcers in two residents. | Level D |
| Failure to assess and manage pain appropriately for one resident with a fracture. | Level D |
| Failure to identify and address irregularities in medication regimen reviews for one resident. | Level D |
| Failure to ensure psychotropic drugs were prescribed and monitored according to regulations, including failure to re-evaluate PRN antipsychotic medication within 14 days. | Level D |
Report Facts
Survey sample size: 8
Facility census: 108
Deficiency count: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator (NHA) | Named in findings related to neurological assessments and pain management |
| E2 | Director of Nursing (DON) | Named in findings related to neurological assessments, pressure ulcer prevention, and pain management |
| E3 | Registered Nurse (RN), Unit Manager (UM) | Named in findings related to pressure ulcer care and pain severity ratings |
| E5 | Certified Nurse Aide (CNA) | Named in observations related to resident positioning and pressure ulcer prevention |
| E6 | Certified Nurse Aide (CNA) | Named in observations related to resident positioning and pressure ulcer prevention |
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