Inspection Report Summary
The most recent inspection on June 17, 2025 found the facility in substantial compliance with no deficiencies identified. Earlier inspections showed a pattern of deficiencies related primarily to resident care, including medication administration, post-fall assessments, abuse investigations, and quality of care, as well as issues with visitation rights, safe environment, and food service. Several complaint investigations were substantiated, particularly concerning care planning, timely notifications, and infection control, but no fines, immediate jeopardy findings, or license actions were listed in the available reports. Most complaints were substantiated, with notable concerns about delayed fall reporting and inadequate abuse investigations. The facility’s recent clean inspection suggests improvement following a period of multiple citations over the past two years.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
18 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
105% worse than Delaware average
Delaware average: 8.8 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
139 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Census: 139
Deficiencies: 0
Jun 17, 2025
Visit Reason
An announced follow-up and complaint survey was conducted at the facility from June 16 through June 17, 2025.
Findings
The facility was found to be in substantial compliance with applicable regulations. No deficiencies were identified at the time of the survey.
Complaint Details
The survey was complaint-related and follow-up in nature. The facility was found to be in substantial compliance.
Report Facts
Survey sample size: 25
Inspection Report
Complaint Investigation
Deficiencies: 6
Apr 18, 2025
Visit Reason
The inspection was conducted due to complaints and allegations regarding visitation restrictions, homelike environment issues, injury investigations, change in condition response, pressure ulcer care, and accident prevention at the nursing home.
Findings
The facility was found to have multiple deficiencies including restricting family visitation rights, failing to maintain a homelike environment by improper disposal of soiled briefs, inadequate investigation of an injury of unknown origin, failure to timely identify and treat a resident's change in condition resulting in immediate jeopardy, failure to provide wound care upon admission, and inadequate supervision leading to resident falls and injuries.
Complaint Details
The complaint investigation included allegations of visitation restriction, failure to maintain a homelike environment, inadequate injury investigation, delayed treatment for change in condition, lack of wound care, and insufficient supervision leading to falls and injuries.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Level of Harm - Immediate jeopardy to resident health or safety: 1
Level of Harm - Actual harm: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to allow family visitation for one resident, restricting visitation rights. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a homelike environment by improper disposal of soiled briefs causing urine odor. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to thoroughly investigate an allegation of injury of unknown origin for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure timely treatment for a resident with a change in condition resulting in immediate jeopardy. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to obtain wound treatment orders and provide wound care upon admission for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide adequate supervision to prevent accidents for two residents, resulting in actual harm. | Level of Harm - Actual harm |
Report Facts
Residents sampled for visitation: 49
Residents sampled for homelike environment: 49
Residents reviewed for abuse: 17
Residents reviewed for change in condition: 4
Residents reviewed for pressure ulcers: 8
Residents reviewed for accidents: 10
Fall incident date: Nov 28, 2024
Fall incident date: Feb 22, 2025
Wound measurement: 48
Wound measurement: 66.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN12 | Licensed Practical Nurse | Reported concerns about resident R162's change in condition and wound care for R170. |
| CNA14 | Certified Nursing Assistant | Reported resident R114 fall and provided care alone despite two-staff requirement. |
| DON1 | Director of Nursing | Provided training and oversight related to change in condition, wound care, and fall prevention. |
| RN2 | Registered Nurse | Reported visitation restriction incident involving family member F4. |
| NP1 | Nurse Practitioner | Evaluated resident R162 and ordered hospital transfer after acute change in condition. |
| F4 | Family Member | Denied visitation rights for resident R10 during night hours. |
| F5 | Family Member | Reported concerns about resident R162's condition and hospital transfer. |
Inspection Report
Recertification Complaint
Census: 158
Deficiencies: 11
Apr 18, 2025
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 04/14/25 to 04/18/25.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified related to visitation rights, safe environment, abuse investigation, transfer/discharge notices, care planning, quality of care, medication errors, food service, and pest control among others.
Complaint Details
The complaint investigation was substantiated as the facility was found not in substantial compliance with multiple regulatory requirements including visitation rights, abuse investigation, and quality of care.
Severity Breakdown
SS=D: 7
SS=C: 1
SS=G: 1
SS=E: 2
Deficiencies (11)
| Description | Severity |
|---|---|
| Facility failed to allow family visitation for one out of 49 sampled residents, violating visitation rights. | SS=D |
| Facility failed to ensure a homelike environment for one resident due to urine odor from soiled briefs. | SS=D |
| Facility failed to thoroughly investigate an allegation of abuse for one resident. | SS=D |
| Facility failed to provide timely and complete transfer/discharge notices for sampled residents. | SS=C |
| Facility failed to develop and revise a person-centered care plan related to falls for one resident. | SS=D |
| Facility failed to ensure timely identification and notification of changes in condition following a fall for one resident. | SS=D |
| Facility failed to ensure wound care treatment orders were obtained and followed for one resident with pressure ulcers. | SS=D |
| Facility failed to provide adequate supervision and assistance devices to prevent accidents for two residents. | SS=G |
| Facility failed to administer medications timely and accurately for two residents. | SS=D |
| Facility failed to ensure meals were provided with no more than a 14-hour gap between evening meal and breakfast for 118 of 158 residents. | SS=E |
| Facility failed to maintain kitchen in sanitary condition and ensure pest control measures were effective. | SS=E |
Report Facts
Survey Census: 158
Sample Size: 49
Supplemental Residents: 12
Deficiencies cited: 12
Residents affected by meal gap: 118
Residents reviewed for falls: 9
Residents reviewed for accidents: 10
Residents reviewed for medication errors: 49
Residents reviewed for transfer notices: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brandi Wilson | Licensed Nursing Home Administrator (LNHA) | Signed the state survey report |
| Administrator1 | Interviewed regarding visitation policy and visitation hours | |
| Director of Nursing (DON) 1 | Director of Nursing | Interviewed regarding visitation, abuse investigation, and care planning |
| Registered Nurse (RN) 2 | Registered Nurse | Interviewed regarding visitation and resident care |
| Licensed Practical Nurse (LPN) 14 | Unit Manager for DelCastle | Interviewed regarding visitation and staff discussions |
| Certified Nursing Assistant (CNA) 16 | Certified Nursing Assistant | Interviewed regarding room conditions and visitation |
| Social Services (SS) | Social Services | Interviewed regarding visitation and family concerns |
| Licensed Practical Nurse (LPN) 6 | Licensed Practical Nurse | Interviewed regarding incontinence care and resident condition |
| Certified Nursing Assistant (CNA) 13 | Certified Nursing Assistant | Interviewed regarding incontinence care and resident condition |
| Licensed Practical Nurse (LPN) 21 | Assistant Director of Nursing (ADON) | Interviewed regarding incontinence care and staff training |
| Family Member (F) 9 | Interviewed regarding resident care and incontinence | |
| Housekeeper (HK) 1 | Housekeeper | Interviewed regarding disposal of soiled briefs |
| Licensed Practical Nurse (LPN) 12 | Licensed Practical Nurse | Interviewed regarding resident condition and medication administration |
| Nursing Home Administrator | Interviewed regarding abuse investigation and staff education | |
| Clinical Consultant | Interviewed regarding abuse investigation | |
| Director of Rehabilitation (DOR) | Director of Rehabilitation | Interviewed regarding therapy staff education |
| Certified Nursing Assistant (CNA) 14 | Certified Nursing Assistant | Interviewed regarding resident fall and care |
| Licensed Practical Nurse (LPN) 8 | Licensed Practical Nurse | Interviewed regarding medication administration |
| Staffing Coordinator | Interviewed regarding incontinence care and medication administration | |
| Dietary Manager (DM) | Dietary Manager | Interviewed regarding meal service and kitchen sanitation |
| Registered Dietician (RD) 2 | Registered Dietician | Interviewed regarding meal service |
| Director of Nursing (DON) 2 | Director of Nursing | Interviewed regarding injury investigation |
| Licensed Practical Nurse (LPN) 19 | Licensed Practical Nurse | Interviewed regarding family contact for hospital transfers |
| Licensed Practical Nurse (LPN) 18 | Licensed Practical Nurse | Interviewed regarding hospital transfer documentation |
| Registered Nurse (RN) 6 | Registered Nurse | Interviewed regarding insulin pen administration |
| Staff Developer/designee | Responsible for staff education on visitation and medication administration | |
| Director of Nursing/designee | Director of Nursing | Responsible for audits and staff education |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Interviewed regarding fall care planning and wound care |
| Maintenance Director (MD) | Maintenance Director | Interviewed regarding kitchen repairs and pest control |
| District Manager of Housekeeping | Interviewed regarding kitchen sanitation and pest control | |
| Wound Care Nurse | Responsible for ensuring wound treatment orders are obtained | |
| Nursing Home Administrator/designee | Responsible for education and audits related to injury and care | |
| Licensed Practical Nurse (LPN) 20 | Licensed Practical Nurse | Interviewed regarding medication administration |
| Registered Nurse (RN) 11 | Registered Nurse | Interviewed regarding resident fall |
| Certified Nursing Assistant (CNA) 10 | Certified Nursing Assistant | Interviewed regarding resident fall and care |
| Nursing Home Administrator (NHA) | Nursing Home Administrator | Interviewed regarding abuse investigation and staff education |
| Licensed Practical Nurse (LPN) 13 | Licensed Practical Nurse | Interviewed regarding visitation and staff replacement |
| Licensed Practical Nurse (LPN) 7 | Licensed Practical Nurse | Interviewed regarding staff training |
| Licensed Practical Nurse (LPN) 1 | Licensed Practical Nurse | Interviewed regarding staff training |
| Director of Rehabilitation (DOR) | Director of Rehabilitation | Interviewed regarding therapy staff education |
| Licensed Practical Nurse (LPN) 8 | Licensed Practical Nurse | Interviewed regarding medication administration |
| Registered Nurse (RN) 6 | Registered Nurse | Interviewed regarding insulin pen administration |
| Staffing Coordinator | Interviewed regarding medication administration | |
| Director of Nursing (DON) 1 | Director of Nursing | Interviewed regarding audits and staff education |
Inspection Report
Routine
Deficiencies: 4
Feb 17, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including post-fall assessments, respiratory care, and laboratory services.
Findings
The facility failed to ensure proper post-fall assessments and monitoring for residents R1 and R3, failed to provide consistent respiratory care including tracheostomy and respiratory mouth care for five residents, and failed to obtain laboratory results for antiseizure medications as ordered for residents R1 and R3.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to obtain and document current vital signs every shift after alert charting was initiated for post-fall monitoring for resident R1. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to monitor resident R3 after a fall which included seizure activity. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide tracheostomy and respiratory mouth care consistent with professional standards for residents R2, R3, R4, R5, and R6. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to obtain antiseizure medication lab results per physician's orders for residents R1 and R3. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Opportunities missed for tracheostomy and respiratory mouth care: 14
Residents affected: 5
Residents affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E7 | LPN | Failed to obtain and document R1's current vital signs during alert charting |
| E8 | LPN | Failed to obtain and document R1's current vital signs during alert charting |
| E9 | LPN | Failed to obtain and document R1's current vital signs during alert charting |
| E3 | Chief Nursing Officer (CNO) | Confirmed findings related to vital signs, respiratory care, and lab results |
| E5 | RN Supervisor | Reported observations of resident R3 seizure activity |
| E6 | Respiratory Therapist (RT) | Provided information on respiratory therapy department responsibilities |
| E12 | Nurse Practitioner (NP) | Acknowledged that current vital signs were not obtained and documented by nursing staff |
Inspection Report
Complaint Investigation
Census: 148
Deficiencies: 3
Feb 17, 2025
Visit Reason
An unannounced complaint survey was conducted at the facility from February 11, 2025 through February 17, 2025 to investigate complaints and assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to ensure residents received proper post-fall assessments and monitoring, respiratory and tracheostomy care, and laboratory services per physician orders. Deficiencies were based on observations, interviews, and record reviews of residents' clinical records and facility documentation.
Complaint Details
The visit was complaint-related, triggered by allegations concerning resident care. The deficiencies were substantiated based on the investigation.
Severity Breakdown
Level D: 2
Level E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure residents received care and services in accordance with physician orders and professional standards for post-fall assessments and monitoring. | Level D |
| Failure to provide respiratory care, including tracheostomy care and respiratory mouth care, consistent with professional standards and the comprehensive person-centered care plan. | Level E |
| Failure to provide or obtain laboratory services only when ordered by a physician and to promptly notify the ordering physician of laboratory results outside clinical reference ranges. | Level D |
Report Facts
Residents sampled: 3
Investigative sample: 6
Facility census: 148
Opportunities for respiratory care: 60
Opportunities for tracheostomy and respiratory mouth care: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brandi Wilson | NHA | Provider's signature on the report |
| E3 | Chief Nursing Officer (CNO) | Interviewed and findings reviewed with this employee |
| E5 | RN Supervisor | Interviewed regarding resident condition |
| E1 | Nursing Home Administrator (NHA) | Exit conference participant |
| E2 | Director of Nursing (DON) | Exit conference participant |
| E10 | Corporate Nurse | Exit conference participant |
| E11 | Corporate Nurse | Exit conference participant |
Inspection Report
Deficiencies: 5
Mar 21, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations ensuring a safe, clean, comfortable, and homelike environment for residents.
Findings
The facility failed to provide a homelike environment for five of 49 sampled residents, with issues including broken and stained privacy curtains, ceiling stains, unclean rooms with trash and dust, and delayed maintenance responses.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Resident's privacy curtain partially detached and broken. | Level of Harm - Minimal harm or potential for actual harm |
| Ceiling over resident's bed had reddish stains and water stains on privacy curtain. | Level of Harm - Minimal harm or potential for actual harm |
| Resident's room observed with trash and towel on the floor, dust and stains on air conditioning unit and television stand. | Level of Harm - Minimal harm or potential for actual harm |
| Privacy curtain with multiple spatter stains, damaged netting, and ceiling with brown spatter stains. | Level of Harm - Minimal harm or potential for actual harm |
| Red spatter marks on ceiling over resident's bed; privacy curtain partially detached and broken. | Level of Harm - Minimal harm or potential for actual harm |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Manager of Housekeeping | Present during observations confirming environmental deficiencies. | |
| Maintenance Director | Interviewed regarding repair attempts and communication with housekeeping. | |
| Director of Nursing | Interviewed regarding environmental checks on residents' rooms. |
Inspection Report
Routine
Deficiencies: 7
Mar 21, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident care, environment, assessments, care planning, nutrition, pain management, trauma-informed care, and pharmaceutical services.
Findings
The facility failed to maintain a safe, clean, and homelike environment for residents, accurately code assessments, provide advance notice for care plan meetings, obtain timely reweighs after significant weight loss, ensure timely delivery and administration of pain medications, and provide trauma-informed, culturally competent care. Several residents experienced environmental issues, inaccurate assessments, missed care plan participation, significant weight loss without timely reweigh, unresolved pain due to medication delivery issues, and inadequate trauma care planning.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to provide a safe, clean, comfortable, and homelike environment for five of 49 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to accurately code the Minimum Data Set (MDS) assessment for one of 49 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide advance notice of care plan meetings and ensure resident participation for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain a reweigh within 48 hours after a 26.3-pound weight loss for one of four residents reviewed for nutrition. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure timely delivery and administration of narcotic pain medications, failed to offer non-pharmacy interventions, and failed to recognize pharmacy delivery issues for one resident reviewed for pain management. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide trauma-informed, culturally competent care accounting for residents' experiences and preferences to avoid triggers for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to identify issues related to timely delivery of pain medications and failed to collaborate with pharmacy to ensure ordering process for controlled substances for one resident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 49
Weight loss: 26.3
Missed doses: 10
BIMS scores: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN10 | Licensed Practical Nurse | Confirmed missed doses of pain medication and issues with reweigh for Resident 104 and pain medication delivery for Resident 73 |
| Director of Nursing | Director of Nursing (DON) | Provided information on environmental checks, care plan participation, and pain medication prior authorization |
| Manager of Housekeeping | Manager of Housekeeping (MH) | Confirmed environmental deficiencies including privacy curtain and ceiling stains |
| Maintenance Director | Maintenance Director | Discussed repair attempts and communication with housekeeping regarding environmental issues |
| Social Services Director | Social Services Director (SSD) | Discussed care conference scheduling and resident notification |
| Certified Nursing Assistant 7 | Certified Nursing Assistant (CNA) | Reported resident complaints of pain and requests for medication |
| LPN4 | Licensed Practical Nurse | Reported communication with pharmacy regarding delayed pain medication delivery |
| Director of Quality | Director of Quality at pharmacy provider | Provided information on pharmacy delivery cutoff times and narcotic ordering procedures |
| Minimum Data Set Coordinator | Minimum Data Set Coordinator (MDSC) | Acknowledged incorrect MDS coding for resident discharge |
Inspection Report
Re-Inspection
Census: 161
Deficiencies: 7
Mar 21, 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 03/18/24 to 03/21/24.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified in areas including safe environment, accuracy of assessments, care plan timing and revision, nutrition/hydration status maintenance, pain management, trauma informed care, and pharmacy services.
Deficiencies (7)
| Description |
|---|
| Facility failed to provide a safe, clean, comfortable, and homelike environment for five of 49 sampled residents. |
| Facility failed to accurately reflect the resident's status in the Minimum Data Set (MDS) assessments. |
| Facility failed to provide one resident advance notice of their care plan meetings and ensure one resident was invited to participate in his quarterly care plan meeting. |
| Facility failed to obtain a reweigh within 48 hours after a 26.3-pound weight loss for one of four residents reviewed for nutrition. |
| Facility failed to ensure narcotic pain medications were delivered in a timely manner and failed to offer additional non-pharmacy interventions or medications for pain management. |
| Facility failed to ensure trauma survivors received culturally competent, trauma-informed care accounting for residents' experiences and preferences. |
| Facility failed to provide routine and emergency drugs and biologicals to residents or obtain them under an agreement as required. |
Report Facts
Survey Census: 161
Sample Size: 49
Weight loss: 26.3
Deficiency completion dates: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| R73 | Resident referenced in pain management deficiency and medication delivery issues | |
| LPN10 | Licensed Practical Nurse | Confirmed missed weight reweighs and medication delivery issues |
| Director of Nursing (DON) | Director of Nursing | Stated facility completed environmental checks and residents should be given advance notice for care conferences |
| Maintenance Director | Attempted to repair environmental concerns | |
| Manager of Housekeeping (MH) | Confirmed environmental observations and cleaning schedules | |
| Social Services Director (SSD) | Social Services Director | Stated care conferences would be held with residents and family members |
| LPN4 | Licensed Practical Nurse | Reported medication delivery communication issues |
| Certified Nursing Assistant (CNA) 7 | Certified Nursing Assistant | Reported resident pain complaints |
Inspection Report
Complaint Investigation
Census: 162
Deficiencies: 0
Jan 30, 2024
Visit Reason
An unannounced complaint survey was conducted at the facility from January 29, 2024 through January 30, 2024.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 Subpart B Requirements for Long Term Care Facilities. No deficiencies were identified during the survey.
Complaint Details
The survey was complaint-related and included observations, interviews, and review of residents' clinical records. No deficiencies were identified, indicating substantial compliance.
Report Facts
Survey sample residents: 3
Inspection Report
Complaint Investigation
Deficiencies: 7
Oct 17, 2023
Visit Reason
The inspection was conducted to investigate complaints related to quality of care, medication administration errors, transportation issues, physician oversight, and clinical documentation accuracy at Cadia Rehabilitation Pike Creek.
Findings
The facility was found deficient in multiple areas including failure to notify providers of significant resident condition changes, medication administration errors, inadequate transportation policies, failure to resume anticoagulant medication post-procedure leading to resident death, and inaccurate clinical documentation by providers.
Complaint Details
The complaint investigation included issues such as failure to notify providers of significant changes in resident condition, medication administration errors, inadequate transportation arrangements, failure to resume critical medications post-procedure, and inaccurate clinical documentation by providers.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Level of Harm - Immediate jeopardy to resident health or safety: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure provider was consulted for a significant change in resident R1's condition with elevated heart rate prior to hospitalization. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure nurse who prepared medications administered them, resulting in medication administration error for resident R3. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate treatment and care for resident R2 who was transported to an outpatient center without an appointment and waited over five hours for return transport, missing lunch and medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure physician reviewed resident R5's total care including medications, resulting in failure to restart Eliquis anticoagulant post-procedure causing resident death. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to ensure resident R4 received correct dose of insulin, resulting in accidental overdose and hospitalization. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to safeguard resident-identifiable information and maintain accurate medical records, including inaccurate documentation of tracheostomy type for resident R1 and failure to update contact information. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure provider accurately documented and responded to clinical lab work for resident R19. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 19
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Medication dose error: 100
Medication prescribed dose: 15
Serum sodium lab values: 125
Serum sodium lab values: 133
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E46 | LPN | Prepared medications for R3 but did not administer them |
| E47 | LPN | Administered medications to R3 prepared by another nurse |
| E4 | LPN | Administered incorrect insulin dose to R4 |
| E6 | MD | Ordered discontinuation of Eliquis for R5 pre-procedure |
| E7 | NP | Reviewed R5's care but unaware Eliquis was discontinued |
| E1 | NHA | Participated in exit conference and interviews |
| E2 | DON | Participated in exit conference and interviews |
| E5 | CNO | Participated in exit conference and interviews |
| E15 | Corporate consultant | Participated in exit conference |
| E16 | Corporate nurse | Participated in exit conference |
Inspection Report
Complaint Investigation
Census: 166
Deficiencies: 5
Oct 12, 2023
Visit Reason
An unannounced Complaint Survey was conducted at the facility from October 12, 2023 through October 17, 2023 to investigate complaints and assess compliance with regulatory requirements.
Findings
The survey identified multiple deficiencies related to notification of changes in resident condition, medication administration, quality of care, physician visits, resident records, and transport policies. Specific issues included failure to notify providers of significant changes, medication errors, inadequate implementation of care plans, and improper documentation.
Complaint Details
The visit was an unannounced complaint survey conducted from October 12 to October 17, 2023. The deficiencies were based on observations, interviews, clinical record reviews, and facility documentation. The facility census on the first day was 166 residents, with a survey sample size of 19 residents.
Deficiencies (5)
| Description |
|---|
| Failure to ensure the provider was consulted for a significant change in a resident's condition. |
| Failure to implement medication administration according to professional standards, including medication errors and improper documentation. |
| Failure to provide quality care, including issues with resident transport and medication reconciliation. |
| Failure to ensure physician visits met regulatory requirements, including review of total program of care and documentation. |
| Failure to maintain resident records with accurate and complete documentation. |
Report Facts
Facility census: 166
Survey sample size: 19
Resident heart rate range: 120
Resident heart rate range: 154
Hospitalization days: 19
Medication administration errors: 5
Audit compliance period: 3
Medication administration error date: 2023
Abatement date: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Hanson | Mentioned as author of patient safety guidelines on medication administration. | |
| Lisa M. Haddad | Mentioned as author of patient safety guidelines on medication administration. | |
| E46 | Licensed Practical Nurse (LPN) | Involved in medication administration and documentation errors related to resident R3. |
| E47 | Licensed Practical Nurse (LPN) | Involved in medication administration and documentation errors related to resident R3. |
| 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; confirmed nursing education completion. |
| E5 | Chief Nursing Officer (CNO) | Participated in exit conference and review of findings. |
| E15 | Corporate Consultant | Participated in exit conference and review of findings. |
| E16 | Corporate Nurse | Participated in exit conference and review of findings. |
| E4 | Licensed Practical Nurse (LPN) | Involved in medication administration error and education of staff. |
| E8 | Reviewed clinical lab work and progress notes related to resident R19. | |
| E11 | Licensed Practical Nurse (LPN) | Confirmed completion of nursing competencies and education. |
| E12 | Registered Nurse (RN) | Confirmed completion of nursing competencies and education. |
| E14 | Registered Nurse (RN) | Confirmed completion of nursing competencies and education. |
Inspection Report
Follow-Up
Census: 117
Deficiencies: 0
Apr 13, 2023
Visit Reason
An unannounced Follow-Up Survey for the Annual and Complaint Survey ending February 23, 2023, was conducted by the State of Delaware Division of Health Care Quality Office of Long Term Care Residents Protection from April 12, 2023 through April 13, 2023.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care as of March 24, 2023. No deficiencies were identified at the time of the survey.
Report Facts
Survey sample size: 20
Inspection Report
Deficiencies: 1
Feb 23, 2023
Visit Reason
The inspection was conducted to review compliance related to physician orders and care for residents with Gastrojejunostomy (GJ) tubes, specifically to verify that active physician orders clearly specified which port of the GJ tube to use for administering medications, tube feedings, checking residuals, and tube placement.
Findings
The facility failed to ensure that active physician orders for two residents with GJ tubes (R54 and R80) clearly specified which port (gastric or jejunal) to use for medication administration, tube feedings, residual checks, and tube placement. Interviews with nursing and medical staff confirmed a lack of clarity and knowledge regarding the correct port to use.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure that active physician orders clearly specified which port of the GJ tube to use when administering medications, tube feedings, checking residual and tube placement for two residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 2
Medication residual volume threshold: 100
Feeding rates and volumes: 45
Feeding duration: 20
Total feeding volume: 900
Water flush rate: 30
Water flush total volume: 600
Feeding rate: 60
Feeding duration: 20
Total feeding volume: 1200
Flush rate: 15
Flush total volume: 300
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E24 | Nurse Practitioner (NP) | Interviewed regarding physician orders for resident R54; stated R54 was not her patient and did not know which GJ tube port to use |
| E21 | RNAC | Consulted during interview about which GJ tube port to use; deferred as medical question |
| E27 | Medical Director | Attempted to be contacted during survey but did not answer |
| E1 | Chief Nursing Officer (CNO) | Discussed findings with surveyor and nursing staff during exit conference |
| E2 | Nursing Home Administrator (NHA) | Participated in exit conference reviewing findings |
| E3 | Director of Nursing (DON) | Participated in exit conference reviewing findings |
Inspection Report
Routine
Deficiencies: 8
Feb 23, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, infection control, medication management, and care planning at Cadia Rehabilitation Pike Creek.
Findings
The facility was found deficient in multiple areas including failure to ensure call bells were within reach, failure to obtain required beneficiary protection signatures, incomplete care plans, inadequate interdisciplinary team participation in care planning, improper catheter care, medication storage and labeling issues, kitchen handwashing station maintenance, and significant infection control failures during a norovirus outbreak including lack of contact precautions, inadequate staff education, and improper wound care.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure a call bell was in reach for one resident (R105). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain resident's signature or document refusal on Notice of Medicare Non-Coverage for one resident (R223). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop a comprehensive person-centered care plan for two residents (R102 and R619). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure required interdisciplinary team members attended or participated in care plan meeting for one resident (R97). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate care to prevent urinary tract infection for one resident (R108) when catheter bag was lying on a visibly soiled floor. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medications were stored and labeled properly in medication carts and medication room. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain kitchen handwashing stations properly, including blocked access and missing signage. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain an infection prevention and control program during a norovirus outbreak, including failure to implement contact precautions, lack of staff education, absence of signage and PPE, failure to monitor staff illness, and improper wound care. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Residents reviewed for care plans: 35
Residents reviewed for beneficiary protection notification: 3
Residents with gastrointestinal symptoms: 46
Residents reviewed for urinary catheters/UTI: 4
Medication carts reviewed: 5
Medication rooms reviewed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E19 | LPN | Confirmed call bell out of reach and medication storage issues |
| E1 | Chief Nursing Officer (CNO) | Findings reviewed with during exit conferences and interviews |
| E2 | Nursing Home Administrator (NHA) | Findings reviewed with during exit conferences and interviews |
| E3 | Director of Nursing (DON) / Infection Control | Reviewed infection control findings and outbreak management |
| E22 | Social Worker (SW) | Interviewed regarding beneficiary protection notification process |
| E23 | Social Worker (SW) | Interviewed regarding beneficiary protection notification process |
| E5 | Respiratory Therapist | Acknowledged lack of respiratory care plan for resident R619 |
| E21 | RNAC | Interviewed about missing ADL care plan for resident R102 |
| E29 | Food Service Director | Confirmed kitchen handwashing station deficiencies |
| E30 | CNA | Confirmed catheter bag on soiled floor |
| E9 | RN/LPN | Confirmed medication storage issues and interviewed about GI illness outbreak |
| E8 | LPN | Interviewed about lack of contact precautions for resident R167 |
| E14 | LPN | Observed performing wound care with contaminated supplies |
| E6 | CNA | Interviewed about knowledge of stomach virus among residents |
| E7 | CNA | Interviewed about knowledge of stomach virus among residents |
| E24 | Nurse Practitioner (NP) | Documented resident R417's GI symptoms and treatment |
Inspection Report
Annual Inspection
Census: 125
Deficiencies: 7
Feb 23, 2023
Visit Reason
An unannounced Annual and Complaint Survey was conducted at the facility from February 13, 2023 through February 23, 2023 to assess compliance with state and federal regulations for skilled and intermediate care nursing facilities.
Findings
The facility failed to meet the minimum staffing requirement of 3.28 hours of direct care per resident per day for three days and failed to ensure reasonable accommodations, proper Medicaid/Medicare coverage notifications, comprehensive care plans, proper bowel and bladder care, medication storage and labeling, infection control, and other regulatory requirements. A norovirus outbreak was identified and the facility failed to fully implement infection control measures.
Deficiencies (7)
| Description |
|---|
| Facility failed to provide staffing at a level of at least 3.28 hours of direct care per resident per day for three days. |
| Facility failed to ensure a call bell was within reach for one resident. |
| Facility failed to obtain signature or document refusal for Notice of Medicare Non-Coverage for discharged residents. |
| Facility failed to develop comprehensive person-centered care plans for two residents. |
| Facility failed to ensure proper bowel and bladder care for residents with urinary catheters and fecal incontinence. |
| Facility failed to ensure medications were stored and labeled properly, including opened medications without expiration dates. |
| Facility failed to maintain an effective infection prevention and control program, including failure to control a norovirus outbreak. |
Report Facts
Facility census: 125
Survey sample size: 67
Direct care hours per resident per day: 3.28
Direct care hours per resident per day observed: 3.15
Direct care hours per resident per day observed: 3.21
Direct care hours per resident per day observed: 3.19
Residents reviewed for call bell: 5
Residents reviewed for Notice of Medicare Non-Coverage: 3
Residents sampled for care plans: 35
Residents reviewed for interdisciplinary team participation: 35
Residents reviewed for bowel/bladder care: 4
Norovirus outbreak residents documented: 46
Norovirus outbreak residents affected: 9
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 1
Aug 18, 2021
Visit Reason
An unannounced COVID-19 Focused Infection Control and complaint survey was conducted at the facility from August 17, 2021 through August 18, 2021.
Findings
The facility was found to be in compliance with COVID-19 infection control regulations but failed to maintain the minimum nursing staffing level of 3.28 hours of direct care per resident per day for two days reviewed. Staffing shortages were due to COVID-19 outbreaks affecting nursing staff.
Complaint Details
The survey was complaint triggered and included a COVID-19 Focused Infection Control component. The complaint was substantiated by findings related to staffing shortages during a COVID outbreak.
Deficiencies (1)
| Description |
|---|
| Failure to maintain minimum nursing staffing level of 3.28 hours of direct care per resident per day on 8/7/2021 and 8/8/2021. |
Report Facts
Census: 108
PPD (hours of direct care per resident per day): 2.9
PPD (hours of direct care per resident per day): 3.19
Minimum required PPD: 3.28
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 0
Mar 1, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and Complaint Survey was conducted by the State of Delaware Division of Health Care Quality from February 17, 2021 through March 1, 2021.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented the CMS and CDC recommended practices to prepare for COVID-19. No deficiencies were identified at the time of the survey.
Complaint Details
The survey included a complaint investigation component; however, no deficiencies were identified.
Report Facts
Facility census: 95
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 2
Jan 11, 2021
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 from January 5, 2021 to January 11, 2021.
Findings
The facility failed to ensure that one of three sampled residents received treatment and care in accordance with professional standards for post-fall assessment and monitoring, resulting in a three-day delay in reporting a fall. Additionally, the facility failed to ensure appropriate use of transfer devices to prevent accidents for one resident.
Complaint Details
The survey was complaint-related, focusing on infection control and specific allegations regarding fall reporting and transfer device use. The findings indicate substantiated deficiencies related to delayed fall reporting and improper use of transfer devices.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure one resident received timely post-fall assessment and monitoring after a fall on 12/14/2021, with a three-day delay in reporting the fall. | SS=D |
| Failure to ensure appropriate transfer devices were used to prevent accidents, including improper validation of transfer status and use of mechanical lifts. | SS=D |
Report Facts
Survey sample size: 7
Facility census: 91
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E5 CNA | Certified Nurse's Aide | Involved in fall incident and reporting |
| E6 CNA | Certified Nurse's Aide | Involved in fall incident and reporting |
| E2 DON | Director of Nursing | Confirmed fall reporting delays and participated in exit conference |
| E3 ADON | Assistant Director of Nursing | Discussed fall incident during investigation |
| E1 NHA | Nursing Home Administrator | Participated in exit conference |
Inspection Report
Routine
Deficiencies: 16
Sep 4, 2019
Visit Reason
The inspection was conducted as a routine survey of the nursing home to assess compliance with regulatory requirements and resident care standards.
Findings
The facility was found to have multiple deficiencies including failure to accommodate resident needs, failure to notify physicians of treatment refusals, inadequate care planning, failure to meet professional standards of quality, medication errors, insufficient staffing, infection control lapses, and failure to provide timely diagnostic and dental services.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 14
Level of Harm - Actual harm: 2
Deficiencies (16)
| Description | Severity |
|---|---|
| Failed to provide reasonable accommodation for a blind resident (R33) by not ensuring call bell was within reach. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify physician when resident (R209) repeatedly refused physician-ordered treatment (BIPAP). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement comprehensive care plans for residents (R19, R51, R58) addressing family non-compliance, lab refusals, and chronic pain. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to meet professional standards of quality for residents (R29, R53) including failure to document assessments and question incorrect medication orders. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate treatment and care for residents (R84, R209) including delayed wound identification and failure to obtain weight as ordered. | Level of Harm - Actual harm |
| Failed to maintain sufficient nursing staff to meet residents' needs safely for residents (R1, R48, R56). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate care for resident (R67) to maintain or improve range of motion by not ensuring hand splint was worn as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure resident environment was free from accident hazards and provide adequate supervision to prevent accidents for residents (R19, R84). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate catheter care and prevent urinary tract infections for resident (R84) with indwelling catheter. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide enough food/fluids to maintain residents' health for residents (R209, R30). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure licensed pharmacist performed monthly drug regimen review and act on irregularities for residents (R30, R53). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents were free from significant medication errors for residents (R90, R209, R211). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide or obtain dental services for resident (R30). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to safeguard resident-identifiable information and maintain accurate medical records for resident (R67). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide and implement an infection prevention and control program including proper isolation, PPE use, hand hygiene, equipment sanitizing, and housekeeping practices. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to date and discard expired medications on medication carts. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Days BIPAP refused: 6
Weight change percentage: 7.45
Fluid intake exceeding restriction days: 19
Medication error dose: 90
Medication error dose: 4
INR lab result: 5.3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | NHA | Reviewed findings during exit conferences and interviews. |
| E2 | DON | Reviewed findings during exit conferences and interviews. |
| E3 | ADON | Reviewed findings during exit conferences and interviews. |
| E4 | NP | Wrote progress notes regarding refusal of BIPAP and lab orders. |
| E17 | RNAC | Followed up with physician regarding eye drops and medication administration. |
| E47 | LPN | Administered wrong insulin to resident R211. |
| E29 | Housekeeper | Observed failing to follow isolation room cleaning procedures. |
| E30 | RT | Observed failing to sanitize hands and improper PPE use. |
| E31 | Housekeeper | Observed failing to follow isolation room cleaning procedures. |
| E36 | CNA | Documented hand splint use inaccurately for resident R67. |
| E12 | CNA | Unable to find hand splint for resident R67 and inaccurately documented its use. |
| E27 | RT | Observed failing to change PPE and sanitize hands between residents. |
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