Inspection Report Summary
The most recent inspection on March 27, 2025 identified deficiencies related to grievances, abuse and neglect, quality of care, medication errors, infection control, and other regulatory requirements. Earlier inspections also noted issues with abuse and neglect, medication errors, infection control, and documentation, with substantiated complaints leading to staff terminations in some cases. Inspectors cited recurring themes of failure to protect residents from abuse, inadequate investigation and reporting of abuse allegations, medication administration errors, and lapses in infection control practices. Several complaint investigations were substantiated, including cases involving abuse and neglect as well as incomplete medical records contributing to adverse outcomes. The inspection history shows ongoing challenges with resident safety and care quality, with no clear improvement trend in recent years.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
7.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
16% better than Delaware average
Delaware average: 8.8 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
111 residents
Based on a March 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 4
Dec 1, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to provide a fully functional phone and private phone access for resident R1, failure to have attending physician participation in care plan meetings for multiple residents, failure to provide medically-related social services for resident R1 with paranoid personality disorder, and failure to accurately document responsible party for resident R3.
Findings
The facility failed to provide R1 with a fully functional phone or private phone access, failed to have attending physician participation in care plan meetings for five residents (R1, R2, R3, R4, R5), failed to provide medically-related social services to R1 despite documented paranoia and cognitive decline, and failed to accurately document the responsible party for R3 despite cognitive impairment.
Complaint Details
The investigation was complaint-driven, focusing on issues raised about communication access for R1, care plan meeting participation by attending physicians, social services provision for R1, and documentation of responsible party for R3.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to provide R1 with a fully functional phone or a private location for calls without being overheard. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to have evidence of attending physician participation in IDT care plan meetings for five residents (R1, R2, R3, R4, R5). | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide medically-related social services to R1, a resident with paranoid personality disorder and cognitive decline. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to accurately document that R3 had a responsible party who makes medical decisions despite moderate cognitive impairment. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for communication: 5
Residents reviewed for care plans: 5
Residents reviewed for social services: 5
BIMS score for R1 on 6/17/25: 15
BIMS score for R1 on 9/11/25: 0
BIMS score for R3 on 7/28/25: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | NHA (Nursing Home Administrator) | Interviewed regarding phone access for R1, attending physician participation, and responsible party documentation. |
| E2 | DON (Director of Nursing) | Participated in exit conferences reviewing findings. |
| E3 | Physician | Documented progress notes on R1's paranoid ideation and refusal of therapy. |
| E4 | SSD (Social Services Director) | Interviewed about social services and family contact for R1. |
| E5 | SSA (Social Services Assistant) | Managed social services for R1, interviewed about phone access and social services follow-up. |
| E6 | NP (Nurse Practitioner) | Documented progress notes on R1's paranoia and refusal of therapy. |
| E12 | ST (Speech Therapist) | Conducted BIMS assessment for R1. |
| E13 | RN (Registered Nurse) | Conducted BIMS assessment for R1. |
| E14 | ADON (Assistant Director of Nursing) | Interviewed about R1's behavior and phone use. |
| E15 | LPN (Licensed Practical Nurse) | Interviewed about R1's behavior changes post-COVID. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Mar 27, 2025
Visit Reason
The inspection was conducted based on complaints and concerns raised regarding the facility's grievance process, notification of transfers and bed holds, catheter care, garbage management, and infection prevention and control practices.
Findings
The facility failed to properly inform residents about the grievance policy, provide timely written notification of hospital transfers and bed hold policies, ensure proper catheter bag positioning, maintain the outdoor garbage area to prevent pests, and follow infection prevention protocols including proper PPE use and hand hygiene.
Complaint Details
The complaint investigation was triggered by concerns about the grievance process, failure to notify residents of hospital transfers and bed hold policies, improper catheter care, garbage management issues, and breaches in infection prevention and control practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to inform residents about the facility's grievance policy and grievance official, and failed to resolve grievances adequately. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide timely written notification of facility-initiated hospital transfers to residents or their representatives. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide written notice of bed hold policy to resident or representative within 24 hours of emergency hospital transfer. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure urinary catheter bag was properly positioned and covered to prevent contamination. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain outdoor garbage/dumpster area to prevent pests from accessing garbage; dumpster lacked lid and had torn bags with food visible. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow infection prevention and control protocols including proper hand hygiene, use of PPE, changing gloves during incontinent care, and proper medication handling. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents unaware of grievance policy: 7
Residents reviewed for hospital transfer notification: 4
Residents reviewed for bed hold notice: 3
Residents reviewed for catheter care: 6
Residents affected by infection control breaches: Many
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Director | Social Service Director (SSD) | Named in grievance process failure and grievance handling. |
| Administrator | Administrator | Responsible for grievance oversight and hospital transfer notification. |
| Housekeeping Director | Housekeeping Director (HD) | Involved in grievance investigation related to housekeeping. |
| Director of Nursing | Director of Nursing (DON) | Involved in grievance investigations and hospital transfer process. |
| Licensed Practical Nurse Supervisor | Licensed Practical Nurse Supervisor (LPNS) | Mentioned in grievance and infection control observations. |
| Certified Nursing Assistant | Certified Nursing Assistant (CNA) | Mentioned in infection control observations and missing electric razor incident. |
| Activity Assistant | Activity Assistant (AA) | Aware of missing electric razor and grievance process. |
| Director of Nursing | Director of Nursing (DON) | Discussed hospital transfer notification and infection control. |
| Infection Preventionist | Infection Preventionist (IP) | Provided infection control policy and observations. |
| Heavy Housekeeping | Heavy Housekeeping (HH) | Observed not using PPE during cleaning of contact precaution room. |
Inspection Report
Recertification Complaint
Census: 111
Deficiencies: 12
Mar 27, 2025
Visit Reason
A Recertification and Complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of the Centers for Medicare and Medicaid Services (CMS) from 03/10/25 through 03/27/25 to assess compliance with federal regulations.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified related to grievances, abuse and neglect, quality of care, medication errors, infection control, and other regulatory requirements.
Complaint Details
The survey included complaint investigations related to grievances, abuse, neglect, medication errors, and quality of care. Several residents and family members reported concerns. The facility failed to follow grievance policies and failed to protect residents from abuse and neglect. The complaint was substantiated with multiple deficiencies cited.
Severity Breakdown
F 585: 1
F 600: 1
F 623: 1
F 684: 2
F 689: 1
F 690: 1
F 880: 1
F 609: 1
F 610: 1
F 759: 1
F 625: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to inform residents about the facility's grievance policy and failure to follow grievance procedures. | F 585 |
| Failure to protect residents from abuse, neglect, exploitation, and misappropriation of resident property. | F 600 |
| Failure to provide notice requirements before transfer or discharge. | F 623 |
| Failure to ensure quality of care including following physician orders and medication administration. | F 684 |
| Failure to ensure free of accident hazards and supervision/devices to prevent accidents. | F 689 |
| Failure to ensure bowel/bladder continence and appropriate catheter care. | F 690 |
| Failure to maintain infection prevention and control program including hand hygiene and transmission-based precautions. | F 880 |
| Failure to report alleged violations of abuse, neglect, exploitation, and mistreatment in a timely manner. | F 609 |
| Failure to investigate and prevent further potential abuse and neglect. | F 610 |
| Failure to ensure medication error rates less than 5 percent and proper medication administration. | F 759 |
| Failure to provide notice of bed hold policy before transfer or discharge. | F 625 |
| Failure to ensure residents receive treatment and care in accordance with professional standards. | F 684 |
Report Facts
Survey Census: 111
Sample Size: 41
Deficiencies cited: 12
Medication error rate: 10
Medication error threshold: 5
Residents reviewed for abuse: 41
Residents with abuse reviewed: 3
Residents with grievances: 7
Residents interviewed for grievance: 5
Residents with medication errors risk: 2
Residents with bed hold notice: 3
Residents reviewed for falls: 41
Residents reviewed for catheter care: 6
Residents reviewed for infection control: 53
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Family Member (FM)1 | Reported multiple concerns during resident stay and grievances | |
| Social Service Director (SSD) | Responsible for grievance process and complaint investigations | |
| Licensed Practical Nurse (LPN)2 | Confirmed removal of resident's small refrigerator and medication administration | |
| Director of Nursing (DON) | Interviewed regarding grievances, abuse investigations, and care concerns | |
| Certified Nursing Assistant (CNA)10 | Involved in abuse investigation and terminated pending investigation | |
| Administrator | Oversaw grievance process and abuse investigations | |
| Licensed Practical Nurse (LPN)5 | Reported facility abuse training and observations | |
| Activity Assistant (AA) | Interviewed regarding abuse allegations | |
| Registered Nurse (RN)3 | Observed medication administration and medication errors | |
| Social Service Director (SSD) | Interviewed about abuse training and grievance process | |
| Licensed Practical Nurse (LPN)1 | Interviewed regarding abuse incident | |
| Licensed Practical Nurse (LPN)2 | Interviewed regarding abuse incident and medication administration | |
| Certified Nursing Assistant (CNA)12 | Observed infection control and hygiene practices | |
| Registered Dietitian (RD) | Completed sanitation inspections of kitchen and dumpster area | |
| Maintenance Director (MD) | Reported on dumpster maintenance and waste management | |
| Licensed Practical Nurse (LPN)2 | Observed infection control practices and medication administration | |
| Infection Preventionist (IP) | Interviewed regarding infection control and PPE use |
Inspection Report
Routine
Deficiencies: 8
Mar 27, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident grievance policies, abuse prevention and reporting, medication administration, infection control, fall prevention, and other care standards.
Findings
The facility failed to inform residents about the grievance policy, did not timely report and investigate allegations of abuse, failed to follow medication administration orders and infection control protocols, and did not consistently implement fall prevention interventions. Several residents experienced issues related to grievance handling, abuse incidents, medication errors, and infection control breaches.
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 inform seven residents about the grievance policy and grievance official contact information. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to protect three residents from abuse, including delayed reporting and investigation of staff-to-resident and resident-to-resident abuse. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report alleged staff-to-resident abuse for one resident, resulting in immediate jeopardy that was later removed. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to investigate an injury of unknown origin for one resident after ruling out staff abuse as the cause. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow physician's orders for medication administration for one resident, including failure to take heart rate before administering propranolol. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure fall interventions were followed for one resident, including lack of bilateral floor mats and low bed as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Medication error rate of 10% observed during medication pass, including administration of medications after meals when ordered before meals. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow infection prevention and control protocols including improper use of PPE, failure to perform hand hygiene, and failure to change gloves during incontinent care. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 10
Residents affected by grievance policy failure: 7
Residents affected by abuse failure: 3
Residents affected by abuse reporting failure: 1
Residents affected by injury investigation failure: 1
Residents affected by medication administration failure: 1
Residents affected by fall intervention failure: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA1 | Certified Nursing Assistant | Named in staff-to-resident abuse incident involving Resident 80 |
| CNA10 | Certified Nursing Assistant | Named in abuse investigation involving Resident 359, terminated for poor customer service |
| LPN1 | Licensed Practical Nurse | Received delayed abuse report from CNA2, failed to report abuse allegation timely |
| CNA2 | Certified Nursing Assistant | Witnessed abuse incident involving Resident 80 and CNA1 |
| Social Service Director | Social Service Director | Involved in grievance and abuse investigations |
| Administrator | Administrator | Oversaw grievance process and abuse investigations |
| Director of Nursing | Director of Nursing | Conducted abuse investigations and confirmed medication administration issues |
| Assistant Director of Nursing | Assistant Director of Nursing | Conducted abuse investigations and confirmed fall intervention failures |
| LPN2 | Licensed Practical Nurse | Failed to follow medication administration orders and infection control protocols |
| RN1 | Registered Nurse | Administered medications after resident had eaten, contrary to orders |
| IP | Infection Preventionist | Confirmed infection control breaches and need for PPE use |
| CNA12 | Certified Nursing Assistant | Failed to change gloves during incontinent care |
| LPN4 | Licensed Practical Nurse | Recalled resident quarantine for COVID exposure |
| CNA13 | Certified Nursing Assistant | Confirmed abuse training and resident room changes |
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 8
Mar 7, 2024
Visit Reason
A Recertification and Complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of the Delaware Health and Social Services, Division of Health Care Quality from 03/04/24 to 03/07/24. The facility was found not to be in substantial compliance with 42 CFR 483 subpart B.
Findings
The facility failed to ensure residents were free of significant medication errors and failed to maintain proper infection control procedures related to insulin pen administration and blood glucose monitoring. Additional deficiencies included failure to notify responsible parties of resident condition changes, failure to maintain a safe and clean environment, and substantiated allegations of abuse and neglect involving several residents.
Complaint Details
The complaint investigation substantiated allegations of abuse involving two residents and staff members. The facility failed to ensure timely and thorough investigations and reporting of abuse allegations. Two staff members were terminated following the investigation.
Deficiencies (8)
| Description |
|---|
| Resident's insulin pen was not primed prior to administration, creating potential for inaccurate dosing. |
| Infection control procedures were not followed; insulin pen and blood glucose monitor were placed on an overbed table without a clean barrier and not sanitized before returning to medication cart. |
| Facility failed to notify responsible party for resident with significant change in condition. |
| Resident rooms were not properly cleaned to ensure a homelike environment; heavy buildup of dust and dirt observed. |
| Facility failed to ensure residents were free from abuse, neglect, exploitation, and mistreatment; substantiated abuse involving staff and residents. |
| Facility failed to conduct thorough investigations and timely reporting of alleged abuse. |
| Facility failed to ensure a smoke-free environment; smoking materials found in resident room. |
| Facility failed to comply with binding arbitration agreement requirements. |
Report Facts
Survey Census: 100
Sample Size: 33
Survey Dates: 03/04/24 to 03/07/24
Deficiencies cited: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brandi Wilson | NHA | Administrator signing the state survey report |
| Director of Nursing | DON | Named in interviews related to medication administration and abuse investigations |
| Licensed Practical Nurse 2 | LPN2 | Observed administering insulin incorrectly |
| Certified Nursing Assistant 7 | CNA7 | Involved in abuse allegations substantiated by investigation |
| Certified Nursing Assistant 3 | CNA3 | Witness and reporter of abuse incident |
| Administrator | Administrator | Confirmed incident report was incomplete and oversaw investigation |
| Housekeeping Director | HKD | Observed cleaning deficiencies and provided cleaning procedure |
| Social Service Director 1 | SSD1 | Confirmed confiscation of smoking materials |
| Social Service Director 2 | SSD2 | Confirmed confiscation of smoking materials |
Inspection Report
Complaint Investigation
Deficiencies: 7
Mar 7, 2024
Visit Reason
The inspection was conducted based on complaints and allegations related to failure to notify responsible parties of resident condition changes, inadequate cleaning, abuse allegations, delayed abuse reporting, incomplete abuse investigations, smoking policy violations, and binding arbitration agreement issues.
Findings
The facility was found deficient in multiple areas including failure to notify responsible parties of resident condition changes, inadequate room cleaning, substantiated abuse incidents with staff terminations, delayed reporting of abuse allegations, incomplete investigations of abuse allegations, failure to secure smoking materials and conduct smoking assessments, and failure to allow proper rescission time for binding arbitration agreements.
Complaint Details
The complaint investigation involved multiple residents with issues including failure to notify responsible parties of condition changes, abuse allegations substantiated against staff, delayed abuse reporting, incomplete abuse investigations, smoking policy violations, and binding arbitration agreement rescission period concerns.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure the responsible party for one resident with pressure ulcers was notified of the resident's change in condition. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure one resident's room was properly cleaned to ensure a homelike environment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure two residents reviewed for abuse remained free from physical abuse; substantiated abuse with staff terminations. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report suspected abuse to the State Agency for one resident, placing the resident at risk for further abuse. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a thorough investigation was completed related to allegations of potential abuse for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete a smoking assessment and secure smoking materials for one resident identified as a smoker. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to allow 30 days for a resident or their responsible party to rescind the voluntary binding arbitration agreement after it was signed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for abuse: 6
Rooms observed for cleanliness: 33
BIMS scores: 5
BIMS scores: 15
BIMS scores: 13
BIMS scores: 10
BIMS scores: 3
Incident report delay: 5
Days allowed to rescind arbitration agreement: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA7 | Certified Nursing Assistant | Terminated for rough handling of resident R62. |
| CNA3 | Certified Nursing Assistant | Witnessed and reported rough handling by CNA7 of resident R62. |
| CNA1 | Certified Nursing Assistant | Terminated for rough handling of resident R86. |
| CNA2 | Certified Nursing Assistant | Terminated for rough handling of resident R86. |
| Administrator | Confirmed incomplete incident reports and abuse investigations; confirmed delayed abuse reporting. | |
| Director of Nursing | DON | Confirmed incomplete abuse investigations and substantiated abuse findings. |
| Wound Care Nurse | Confirmed family was not notified of resident R214's abrasion. | |
| Housekeeping Director | HKD | Confirmed inadequate cleaning and planned to retrain staff and clean resident R1's room. |
| Unit Manager 2 | UM2 | Reported CNA7 was not taking care of resident R62 due to rough care. |
| Unit Manager 1 | UM1 | Reported social service staff had taken vapes from resident R61's room. |
| Social Service Director 1 | SSD1 | Confirmed receipt of lighters confiscated from resident R61. |
| Social Service Director 2 | SSD2 | Confirmed receipt of lighters confiscated from resident R61. |
| Certified Nursing Assistant 4 | CNA4 | Aware that resident R61 smoked. |
| Admission Coordinator | Confirmed arbitration agreement allowed only 21 days to rescind. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Mar 27, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding failure to provide required Medicare Part A notices to residents and failure to provide or obtain dental services for residents.
Findings
The facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to resident R74 who remained in the facility after discontinuation of Part A services, and failed to provide the Notice of Medicare Non-Coverage (NOMNC) to resident R255 who was discharged after Part A services ended. Additionally, the facility failed to promptly assist resident R49 with follow-up dental services after reporting lost dentures.
Complaint Details
The investigation was complaint-driven, focusing on failure to provide required Medicare notices to residents R74 and R255, and failure to provide dental services to resident R49. Substantiation status is not explicitly stated.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to resident R74 after discontinuation of Part A services. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide Notice of Medicare Non-Coverage (NOMNC) to resident R255 upon discharge from Part A services. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to promptly assist resident R49 with follow-up dental services after reporting lost dentures. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medicare Part A benefit days remaining: 10
Medicare Part A benefit days remaining: 26
Residents reviewed for Medicare Part A notices: 3
Residents reviewed for dental services: 2
Residents affected by dental deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Director | E4 verified failure to provide SNFABN and NOMNC forms and was involved in dental referral process. | |
| Chief Nursing Officer (CNO) | E1 participated in exit conference and confirmed no evidence of response to lost dentures. | |
| Nursing Home Administrator (NHA) | E2 participated in exit conference. | |
| Director of Nursing (DON) | E3 participated in exit conference. | |
| Dentist | E5 documented need for dentures for resident R49. | |
| Registered Nurse (RN) | E6 was aware of resident R49's lost dentures but did not report to Social Work. |
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 1
Dec 12, 2022
Visit Reason
An unannounced Complaint Survey was conducted at the facility from December 8, 2022 through December 12, 2022 to investigate a complaint regarding resident care and medical record documentation.
Findings
The facility failed to maintain accurate and complete medical records for one resident, including incomplete documentation of vital signs, changes in condition, and emergency responses. This failure impacted the facility's ability to safeguard resident health and safety.
Complaint Details
The complaint investigation found that for one resident (R1), the facility did not ensure accurate and complete records related to a change in condition, including vital signs, oxygen administration, nursing responses, and documentation of 911 calls and paramedic interventions. The resident was sent out via 911 and passed away in transit.
Deficiencies (1)
| Description |
|---|
| Failure to maintain accurate and complete medical records for resident R1, including incomplete documentation of vital signs, changes in condition, and emergency responses. |
Report Facts
Facility census: 107
Survey sample size: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E4 | LPN Supervisor | Interviewed regarding vital signs and documentation for resident R1 |
| E5 | RN | Interviewed regarding observations and care for resident R1 |
| E1 | CNO | Participated in exit conference |
| E2 | NHA | Participated in exit conference |
| E3 | DON | Participated in exit conference and responsible for audits of Code Blue records |
Inspection Report
Follow-Up
Census: 99
Deficiencies: 0
Jan 6, 2021
Visit Reason
An unannounced follow-up survey to the Focused Infection Control and complaint survey ending October 15, 2020 was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19. The facility was also found to be in compliance with 42 CFR, Part 483, Subpart B, Requirements for Long Term Care. No deficiencies were identified at the time of the survey.
Report Facts
Survey sample size: 4
Inspection Report
Routine
Census: 96
Deficiencies: 0
Dec 11, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection from December 9, 2020 through December 11, 2020.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19. No deficiencies were identified at the time of the survey.
Report Facts
Facility census: 96
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 0
Dec 7, 2020
Visit Reason
A COVID-19 Focused Infection Control and a Complaint Survey was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection from December 2, 2020 through December 7, 2020.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has 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 was complaint-related and included a COVID-19 focused infection control component. The facility was found compliant with infection control regulations.
Report Facts
Facility census: 96
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 3
Apr 2, 2019
Visit Reason
An unannounced complaint survey was conducted at the facility from April 2, 2019 through April 5, 2019 to investigate allegations of abuse, neglect, and failure to provide necessary services.
Findings
The facility failed to provide showers as per resident preference and failed to implement policies to prevent abuse and neglect, including failure to thoroughly investigate alleged abuse and to report it timely. One staff member was terminated due to substantiated abuse. The facility has plans to audit and educate staff to prevent recurrence.
Complaint Details
The complaint investigation was substantiated. Specific findings included failure to provide showers as scheduled, verbal and physical abuse by a licensed practical nurse (E10) resulting in termination, and failure to investigate and report abuse allegations timely and thoroughly.
Severity Breakdown
Level 3: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide showers as per resident preference and care plan. | Level 3 |
| Failure to develop and implement policies to prevent abuse, neglect, and exploitation. | Level 3 |
| Failure to thoroughly investigate allegations of abuse and to report results timely. | Level 3 |
Report Facts
Facility census: 113
Survey sample size: 7
Residents reviewed for abuse: 4
Residents reviewed for shower services: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E10 | Licensed Practical Nurse (LPN) | Named in abuse findings; terminated due to substantiated abuse |
| E2 | Director of Nursing (DON) | Interviewed regarding abuse allegations and findings |
| E3 | Assistant Director of Nursing (ADON) | Interviewed and reviewed findings related to abuse investigation |
| E8 | Certified Nurse's Aide (CNA) | Interviewed regarding abuse allegations |
| E9 | Certified Nurse's Aide (CNA) | Interviewed regarding abuse allegations |
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