Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
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
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
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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