Inspection Report Summary
The most recent inspection on September 15, 2025, identified deficiencies related to medication administration and care planning for a resident refusing medications. Earlier inspections showed a pattern of issues involving medication management, nursing staffing shortages, resident rights, and care planning, with substantiated complaints including verbal abuse and failure to report and investigate abuse timely. Inspectors cited recurring problems with medication errors, insufficient staffing, and incomplete or inaccurate care plans. Complaint investigations were mostly substantiated, including a notable case of verbal abuse and several findings related to medication and care plan deficiencies. The facility’s inspection history shows ongoing challenges with medication administration and staffing, with no clear sustained improvement over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
30.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
250% worse than Delaware average
Delaware average: 8.8 deficiencies/yearDeficiencies per year
32
24
16
8
0
Census
Latest occupancy rate
98 residents
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Deficiencies: 4
Sep 15, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to care planning, medication administration, and medication error prevention at Complete Care at Brackenville LLC.
Findings
The facility was found deficient in developing person-centered care plans for medication refusal and ensuring medication administration according to physician orders. Specifically, one resident (R2) lacked a care plan for medication refusal, and another resident (R5) received incorrect doses of intravenous daptomycin due to medication errors involving pharmacy delivery and nursing administration.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to develop a person-centered care plan for refusal of medications for resident R2. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure that resident R5's medication was administered according to the physician's order, including administration of incorrect doses of daptomycin. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure services met professional standards of quality related to medication administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents are free from significant medication errors, including improper labeling and administration of IV medications. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Episodes of medication refusal: 28
Medication doses administered incorrectly: 2
Number of nurses involved in medication error: 3
Medication bags delivered incorrectly: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Director of Nursing (DON) | Confirmed findings related to care plan deficiencies and medication errors; provided interviews and documentation. |
| E1 | Nursing Home Administrator (NHA) | Participated in exit conference reviewing findings. |
| E3 | Registered Nurse (RN) | Participated in exit conference reviewing findings. |
| E4 | Former Weekend RN Supervisor | Counseled regarding medication error. |
| E5 | Former Registered Nurse (RN) | Counseled regarding medication error; admitted to altering medication labeling. |
| E7 | Registered Nurse (RN) | Interviewed about medication administered to resident R5; unable to recall specifics. |
| P1 | IV Pharmacist | Provided information about pharmacy delivery errors and quality control measures. |
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 5
Sep 15, 2025
Visit Reason
An unannounced complaint survey was conducted at the facility from September 11, 2025, through September 15, 2025, based on observations, interviews, and review of clinical records and other documentation.
Findings
The facility failed to develop a comprehensive person-centered care plan for a resident refusing medications and failed to ensure medication administration met professional standards, including errors in medication delivery and documentation. Deficient practices affected residents receiving IV medications and those refusing medications, requiring re-education of nursing staff and audits to ensure compliance.
Complaint Details
The survey was complaint-driven, unannounced, and conducted over five days. Findings were substantiated based on record reviews and interviews, identifying medication administration errors and failure to develop appropriate care plans for residents refusing medications.
Severity Breakdown
Level D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to develop and implement a comprehensive person-centered care plan for a resident refusing medications. | Level D |
| Failure to meet professional standards in medication administration, including undated facility documents and medication errors. | Level D |
| Failure to ensure medication administration according to physician's orders, including incorrect medication doses administered. | Level D |
| Failure to ensure residents are free of significant medication errors. | Level D |
| Failure to thoroughly investigate medication error incidents and ensure proper medication labeling and administration. | Level D |
Report Facts
Facility census: 98
Survey sample size: 5
Medication refusal episodes: 28
Medication administration opportunities: 49
BIMS score: 15
Medication doses: 4
Medication doses: 2
Inspection Report
Deficiencies: 1
Mar 21, 2025
Visit Reason
The inspection was conducted to review compliance with minimum staffing levels for residential health facilities, specifically focusing on nursing staffing ratios as required by Delaware Code Chapter 11, Subchapter VII 1162 Nursing Staffing.
Findings
The facility was found noncompliant with the minimum CNA day shift staffing ratio of 1:8, with a documented CNA ratio of 1:9 during the week of 1/26/25 to 2/1/25. A desk review staffing audit revealed failure to meet the required staffing levels.
Deficiencies (1)
| Description |
|---|
| Failure to maintain the minimum CNA day shift staffing ratio of 1:8. |
Report Facts
CNA staffing ratio: 9
Required CNA staffing ratio: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator | Completed Facility Staffing Worksheets revealing staffing deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 5
Feb 14, 2025
Visit Reason
The inspection was conducted as a comprehensive annual survey of Complete Care at Brackenville LLC to assess compliance with regulatory requirements related to resident care, rights, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to assess and document clinical appropriateness for resident self-administration of medications, failure to promptly address resident council grievances, inaccurate documentation of residents' code status and advance directives, lack of alternative measures prior to bed rail use, and failure to ensure timely response to resident call lights.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to determine if a resident was assessed as clinically appropriate to self-administer medications, resulting in unsafe medication storage and administration practices. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to act promptly on grievances and recommendations of the resident council group for seven of 12 months reviewed, resulting in resident concerns going unaddressed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure accurate code status documentation and availability for two residents, risking non-adherence to residents' wishes regarding advance directives. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure residents received alternative measures prior to installation of bed rails for one resident, potentially compromising safety. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure call lights were answered timely for one resident, potentially putting residents at risk. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Sample residents reviewed: 38
Resident council meeting months reviewed: 12
Residents affected: 7
Residents affected: 2
Residents affected: 1
Residents affected: 1
BIMS score: 15
BIMS score: 9
BIMS score: 5
BIMS score: 7
Observation duration: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 4 | Licensed Practical Nurse | Observed leaving medications unattended and interviewed about resident medication self-administration |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication administration and call light response policies |
| Activity Director | Activity Director | Interviewed regarding resident council meetings and grievance handling |
| Administrator | Administrator and Grievance Officer | Interviewed regarding resident council facilitation and grievance follow-up |
| Regional Operations Manager | Regional Operations Manager | Interviewed regarding training and expectations for resident council meetings |
| LPN 2 | Licensed Practical Nurse | Interviewed about code status and CPR administration |
| Director of Rehab | Director of Rehabilitation | Interviewed about therapy role in bed rail assessment |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed about bed rail assessments and family involvement |
| LPN 1 | Licensed Practical Nurse | Observed and interviewed regarding call light response |
| CNA 9 | Certified Nurse Aide | Observed and interviewed regarding call light response |
| CNA 7 | Certified Nurse Aide | Observed communicating about call light |
| RN 3 | Registered Nurse | Interviewed about call light responsibilities |
Inspection Report
Annual Inspection
Census: 99
Deficiencies: 6
Feb 14, 2025
Visit Reason
An Annual 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.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified related to resident self-administration of medications, resident and family grievances, advance directives, bed rails safety, and sufficient nursing staff response to call lights.
Complaint Details
The survey included a complaint investigation. The facility was found not to be in substantial compliance with 42 CFR 483 subpart B based on complaint allegations.
Severity Breakdown
SS=D: 4
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to determine if one resident was assessed as clinically appropriate to self-administer medications and failure to leave medications at the bedside unattended. | SS=D |
| Failure to act promptly on grievances and recommendations of the resident council group, resulting in resident concerns going unaddressed. | null |
| Failure to support resident rights to organize and participate in resident groups and family groups. | null |
| Failure to ensure accurate code status documentation for residents with advance directives. | SS=D |
| Failure to ensure residents received alternative measures prior to installation of bed rails, leading to potential safety concerns. | SS=D |
| Failure to have sufficient nursing staff with appropriate competencies and skills to assure resident safety and well-being, including timely response to call lights. | SS=D |
Report Facts
Survey Dates: 02/11/25 - 02/14/25
Survey Census: 99
Sample Size: 38
Supplemental Residents: 7
Deficiencies Completion Date: March 26, 2025 for multiple deficiencies
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident R66 | Resident | Named in medication self-administration deficiency |
| Licensed Practical Nurse (LPN) 4 | Licensed Practical Nurse | Observed and interviewed regarding medication administration |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding medication administration and resident capabilities |
| Resident R44 | Resident | Named in staffing and call light response deficiency |
| Certified Nurse Aide (CNA) 9 | Certified Nurse Aide | Observed during call light response observation |
| Activity Director | Activity Director | Interviewed regarding resident council meetings and grievances |
| Administrator | Administrator | Interviewed regarding grievance follow-up and resident council meetings |
| Regional Operations Manager | Regional Operations Manager | Interviewed regarding resident council meeting facilitation |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Interviewed regarding bed rail assessments |
| Director of Rehab (DOR) | Director of Rehab | Interviewed regarding bed rail use |
| Licensed Practical Nurse (LPN) 2 | Licensed Practical Nurse | Interviewed regarding code status and advance directives |
| Resident R9 | Resident | Named in bed rail deficiency |
| Resident R298 | Resident | Named in resident council grievance discussion |
| Resident R12 | Resident | Named in resident council grievance discussion |
| Resident R65 | Resident | Named in resident council grievance discussion |
| Resident R18 | Resident | Named in resident council grievance discussion |
| Resident R57 | Resident | Named in resident council grievance discussion |
| Registered Nurse (RN) 3 | Registered Nurse | Observed during call light monitoring |
Inspection Report
Routine
Deficiencies: 1
Feb 13, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with staffing requirements, specifically to ensure call lights were answered timely for residents.
Findings
The facility failed to ensure call lights were answered timely for one of 38 sampled residents, with a call light left on for 38 minutes, posing potential risk to residents. Interviews and observations confirmed staff did not respond promptly despite policy requiring timely response.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure call lights were answered timely for one of 38 sampled residents, with a call light left on for 38 minutes. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 38
Call light duration: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) 1 | Observed standing by medication cart and acknowledged call light should not be left on for 38 minutes | |
| Certified Nurse Aide (CNA) 9 | Assigned to resident R44 but was helping another resident; agreed call light was left on too long | |
| Certified Nurse Aide (CNA) 7 | Notified CNA 9 about call light being on | |
| Activities Director (AD) | Walked by resident's room twice without answering call light | |
| Registered Nurse (RN) 3 | Observed at nurses' station and stated everyone is responsible for answering call lights | |
| Director of Nursing (DON) | Stated call lights should be answered by all staff and failure to do so could put residents at risk |
Inspection Report
Follow-Up
Census: 91
Deficiencies: 0
Apr 3, 2024
Visit Reason
An unannounced follow-up survey was conducted from April 1 through April 3, 2024, for the annual and complaint survey ending February 2, 2024.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 Subpart B Requirements for Long Term Care Facilities as of March 19, 2024. No deficiencies were identified at the time of the survey.
Report Facts
Survey sample size: 20
Inspection Report
Routine
Deficiencies: 16
Feb 2, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with federal regulations regarding resident rights, medication administration, abuse prevention, fall prevention, staffing, food service, infection control, and other care standards.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity and privacy, improper handling of medication and specimens, verbal abuse substantiated against staff, delayed reporting of neglect, inaccurate resident assessments, inadequate supervision leading to resident falls, improper respiratory equipment storage, insufficient staffing levels, poor food quality and temperature control, extended time between dinner and breakfast, unsanitary kitchen conditions, and lapses in infection control practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 14
Level of Harm - Actual harm: 1
Deficiencies (16)
| Description | Severity |
|---|---|
| Failed to ensure resident dignity and privacy during personal care and elopement risk assessments. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to assess resident for self-administration of medications leading to medications left accessible to others. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to protect resident from verbal abuse by staff; verbal abuse substantiated. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report an allegation of neglect to the State Survey Agency. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to conduct a thorough investigation of an allegation of staff-to-resident verbal abuse. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure accurate Minimum Data Set (MDS) assessments for residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly handle and preserve a biopsied specimen; specimen was discarded prior to analysis. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide adequate supervision to prevent falls resulting in actual harm; resident sustained subdural hematoma after fall. | Level of Harm - Actual harm |
| Failed to provide respiratory care per standards; respiratory equipment was not stored properly increasing risk of contamination. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to have sufficient nursing staff on a 24-hour basis to meet residents' needs and failed to respond timely to resident needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure nurses and nurse aides were competent to provide care in a dignified manner and handle specimens properly. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to secure medication storage room by leaving door propped open. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food was palatable, served at proper temperature, and condiments consistently provided. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure meals and snacks were served with no more than 14-hour gap between dinner and breakfast as required. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain kitchen in sanitary condition including improper food storage, unclean equipment, improper handwashing sink use, uncovered hair, and cross contamination risks. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to clean and disinfect glucometer per manufacturer instructions, failed to perform hand hygiene after glove removal, failed to store trash and personal belongings properly, and failed to wear PPE correctly. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Deficiencies cited: 15
Residents affected: 19
BIMS scores: 15
Staff to resident ratios: 1
Staff to resident ratios: 1
Staff to resident ratios: 1
CNA to resident ratios: 1
CNA to resident ratios: 1
CNA to resident ratios: 1
Meal service time gap: 14.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA3 | Certified Nursing Assistant | Named in privacy and dignity deficiency for failing to pull privacy curtain during personal care |
| LPN5 | Licensed Practical Nurse | Named in specimen handling deficiency for discarding biopsied specimen |
| CNA12 | Certified Nursing Assistant | Named in verbal abuse finding substantiated against this staff member |
| RN2 | Registered Nurse | Named in respiratory care and infection control deficiencies |
| CNA7 | Certified Nursing Assistant | Named in failure to assist resident with dressing and personal care |
| RN3 | Registered Nurse | Named in verbal abuse investigation |
| LPN1 | Licensed Practical Nurse | Named in fall supervision deficiency |
| LPN3 | Licensed Practical Nurse | Named in fall supervision deficiency |
| DA1 | Dietary Aide | Named in kitchen sanitation deficiency for storing personal beverage in food refrigerator |
| DA2 | Dietary Aide | Named in kitchen sanitation deficiency for inadequate hair covering |
| Cook1 | Cook | Named in kitchen sanitation deficiency for cross contamination by using same gloves |
Inspection Report
Recertification And Complaint Investigation
Census: 99
Deficiencies: 30
Feb 2, 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 January 30, 2024 to February 2, 2024.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Multiple deficiencies were identified related to resident rights, self-administration of medications, abuse and neglect, reporting of alleged violations, quality of care, sufficient nursing staff, food safety, infection control, and other regulatory requirements.
Complaint Details
The survey included complaint investigation related to allegations of verbal abuse, neglect, failure to report incidents, and failure to provide adequate care and supervision. The allegation of verbal abuse by CNA12 towards Resident 59 was substantiated. The facility failed to report and investigate abuse and neglect allegations timely and thoroughly.
Severity Breakdown
Level D: 15
Level E: 9
Level G: 2
Deficiencies (30)
| Description | Severity |
|---|---|
| Failure to ensure elopement risks and wander guard assessments were updated to promote dignity and privacy. | — |
| Failure to protect resident privacy by not pulling privacy curtains during care. | — |
| Failure to assess and support resident self-administration of medications safely. | Level D |
| Failure to protect residents from verbal abuse by staff. | Level D |
| Failure to report alleged abuse and neglect in a timely manner. | Level D |
| Failure to investigate allegations of abuse thoroughly. | Level D |
| Failure to report incidents of neglect and abuse to the State Survey Agency timely. | Level D |
| Failure to ensure resident assessments were accurate and complete. | Level D |
| Failure to provide adequate supervision to prevent falls and injuries. | Level G |
| Failure to provide sufficient nursing staff to meet residents' needs. | Level E |
| Failure to maintain resident dignity and respect in care provision. | — |
| Failure to properly handle and store biopsy specimens. | Level D |
| Failure to ensure adequate supervision and assistance for residents at risk for falls. | Level G |
| Failure to provide respiratory care consistent with professional standards. | Level D |
| Failure to store respiratory equipment properly. | Level D |
| Failure to provide sufficient nursing staff with appropriate competencies. | Level E |
| Failure to maintain food safety and sanitation standards. | Level E |
| Failure to maintain a sanitary kitchen and proper food storage. | Level E |
| Failure to maintain safe storage and labeling of drugs and biologicals. | Level D |
| Failure to secure medication storage rooms and maintain medication security. | Level D |
| Failure to maintain infection prevention and control program. | Level D |
| Failure to maintain hand hygiene and PPE use among staff. | Level D |
| Failure to maintain proper cleaning and sanitizing of glucometers. | Level D |
| Failure to maintain proper storage and disposal of personal protective equipment and trash. | Level D |
| Failure to maintain adequate housekeeping and trash disposal. | Level D |
| Failure to maintain proper food temperature and food quality. | Level E |
| Failure to provide sufficient meals and snacks at appropriate times. | Level E |
| Failure to maintain proper food service and dining environment. | Level E |
| Failure to maintain proper labeling and dating of food items. | Level E |
| Failure to maintain proper storage and handling of food items. | Level E |
Report Facts
Survey Census: 99
Sample Size: 22
Supplemental Residents: 48
Deficiency Severity Level D: 15
Deficiency Severity Level E: 9
Deficiency Severity Level G: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant CNA3 | Certified Nursing Assistant | Failed to pull privacy curtain and provide personal care |
| Certified Nursing Assistant CNA12 | Certified Nursing Assistant | Engaged in verbal abuse towards Resident 59; terminated during investigation |
| Registered Nurse RN2 | Registered Nurse | Observed failing to assist residents and monitor care properly |
| Director of Nursing DON | Director of Nursing | Provided statements on facility policies and deficiencies; confirmed CNA12 termination |
| Licensed Practical Nurse LPN5 | Licensed Practical Nurse | Discarded biopsy specimen improperly |
| Registered Nurse RN1 | Registered Nurse | Failed to properly store respiratory equipment and maintain infection control |
| Dietary Manager DM | Dietary Manager | Observed food safety and sanitation deficiencies |
| Registered Dietitian RD | Registered Dietitian | Conducted meal tray audits and identified food safety issues |
| Nurse Practice Educator | Nurse Practice Educator | Responsible for re-educating staff on multiple deficient practices |
Inspection Report
Routine
Deficiencies: 16
Feb 2, 2024
Visit Reason
The inspection was a routine regulatory survey of Complete Care at Brackenville LLC to assess compliance with healthcare facility regulations, including resident rights, medication management, abuse prevention, infection control, staffing, and food service.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity and privacy, improper medication self-administration assessment, verbal abuse substantiated against staff, delayed reporting of neglect, incomplete abuse investigations, inaccurate resident assessments, improper handling of biopsy specimens, inadequate supervision leading to resident falls with injury, respiratory equipment storage issues, insufficient staffing levels, inadequate staff competencies, unsecured medication storage, food quality and temperature concerns, extended time between dinner and breakfast without resident approval, unsanitary kitchen conditions, and lapses in infection prevention and control practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 14
Level of Harm - Actual harm: 1
Deficiencies (16)
| Description | Severity |
|---|---|
| Failed to ensure elopement risk assessments and privacy during personal care, exposing residents and not providing dignity. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to assess resident for self-administration of medications leading to medications left accessible to others. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to protect resident from verbal abuse by staff; verbal abuse substantiated and staff terminated. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report an allegation of neglect to the State Survey Agency. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to conduct a thorough investigation of staff-to-resident verbal abuse allegation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure accurate Minimum Data Set assessments for residents, leading to potential inaccurate care planning. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly handle and preserve a biopsied specimen, which was discarded prior to pathology analysis. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide adequate supervision to prevent falls, resulting in a resident sustaining a subdural hematoma after a fall. | Level of Harm - Actual harm |
| Failed to provide respiratory care per standards, including improper storage of respiratory equipment leading to potential contamination. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to have sufficient nursing staff on a 24-hour basis to meet residents' needs and failed to respond timely to residents' needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure nurses and nurse aides were competent to provide care, including failure to provide privacy during personal care and improper handling of biopsy specimens. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medication storage room was secured by keeping the door closed and locked. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food was palatable, served at safe temperatures, and condiments were consistently provided as per resident preferences. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure meals and snacks were served with no more than a 14-hour gap between dinner and breakfast, without resident group approval for extended time. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain a sanitary kitchen environment, including improper food storage, unclean equipment, lack of handwashing sink use, improper glove use, uncovered hair, and personal items stored improperly. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure glucometer was cleaned and disinfected per manufacturer instructions, failed to perform hand hygiene per policy, failed to store trash and personal belongings properly, and failed to wear PPE correctly. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 6
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 19
Residents affected: 97
Residents affected: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA3 | Certified Nursing Assistant | Failed to provide privacy during personal care to Resident 39 |
| LPN5 | Licensed Practical Nurse | Discarded biopsy specimen improperly for Resident 298 |
| CNA12 | Certified Nursing Assistant | Substantiated verbal abuse towards Resident 59; terminated |
| RN2 | Registered Nurse | Failed to perform hand hygiene properly and improperly cleaned glucometer |
| CNA7 | Certified Nursing Assistant | Failed to assist Resident 89 despite request from RN2 |
| RN3 | Registered Nurse | Alleged verbal abuse towards Resident 346; investigation incomplete |
| LPN3 | Licensed Practical Nurse | Witnessed fall of Resident 297 and documented safety concerns |
| DA1 | Dietary Aide | Stored personal beverage in refrigerator with food |
| DA2 | Dietary Aide | Observed with inadequately covered hair during meal service |
| Cook1 | Cook | Used same gloves to handle ready-to-eat food and other items causing cross contamination risk |
Inspection Report
Follow-Up
Census: 95
Deficiencies: 0
Oct 3, 2022
Visit Reason
An unannounced Follow-up Survey to the Annual, Complaint and Emergency Preparedness Survey ending July 25, 2022 and the Federal Monitoring Survey ending August 25, 2022 was conducted by the State of Delaware Division of Health Care Quality from September 29, 2022 through October 3, 2022.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care as of September 13, 2022.
Report Facts
Sample size: 24
Inspection Report
Routine
Deficiencies: 15
Jul 25, 2022
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to honor resident bathing preferences, inaccurate resident assessments, failure to develop baseline and comprehensive care plans, inadequate discharge documentation, failure to provide appropriate care for pressure ulcers and limited range of motion, improper infection control practices, failure to assist with hearing aids, and failure to provide required staff training on abuse and neglect.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 14
Level of Harm - Actual harm: 2
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to ensure resident R347's bathing preference for showers twice a week was honored. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure accurate assessments for residents R2 and R60 on MDS assessments. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to refer resident R49 for appropriate PASARR Level II evaluation after new diagnosis and medication. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement baseline care plans within 48 hours of admission for residents R196 and R352. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement comprehensive person-centered care plans for six residents (R2, R3, R12, R25, R347, R352). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure necessary information was communicated to residents R350 and R353 and receiving health care providers at discharge. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide care and assistance for activities of daily living for resident R12, including shaving facial hair and trimming fingernails. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate treatment and care according to orders for residents R6 and R98, including failure to complete ordered lab tests and notify physician of critical blood sugar levels. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to assist resident R25 in gaining access to hearing services and proper use of hearing aid. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for residents R57 and R352. | Level of Harm - Actual harm |
| Failed to provide appropriate care for residents R2 and R12 to maintain or improve range of motion and mobility. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide or obtain dental services for resident R12, including follow-up dental care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to procure food from approved sources and serve food according to professional standards; residents did not receive planned menu items or appropriate substitutions. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide and implement an infection prevention and control program, including inadequate hand hygiene, glucometer cleaning, insulin administration, and laundry room ventilation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide required staff education on dementia care and abuse, neglect, exploitation, and reporting for two staff members. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Scheduled showers: 9
Shower refusals or substitutions: 6
Residents sampled: 29
Residents reviewed for discharge: 4
Residents reviewed for pressure ulcers: 5
Residents reviewed for limited ROM: 4
Staff sampled: 22
Residents affected: 6
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 2
Staff affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E16 | Licensed Practical Nurse, Unit Manager | Confirmed findings related to resident bathing preference |
| E1 | Nursing Home Administrator | Participated in exit conferences reviewing findings |
| E2 | Director of Nursing | Participated in exit conferences reviewing findings |
| E15 | Minimum Data Set Coordinator | Confirmed inaccurate MDS assessments and lack of care plans |
| E8 | Social Worker | Confirmed failure to refer for PASARR Level II evaluation |
| E9 | Occupational Therapist | Confirmed lack of splint application and evaluated decreased ROM |
| E23 | Registered Nurse | Confirmed lack of care plan and treatment for limited ROM and hearing aid assistance |
| E18 | Registered Nurse | Observed failing to clean glucometer and perform hand hygiene |
| E6 | Registered Dietician | Confirmed menu substitution and dietary order issues |
| E7 | Food Service Director | Confirmed food service safety and menu substitution issues |
| E3 | Assistant Director of Nursing | Confirmed wound care and discharge documentation deficiencies |
| E31 | Nurse Practitioner | Documented and treated UTI, involved in discharge summary deficiencies |
| E38 | Licensed Practical Nurse | Involved in abuse and neglect incident, lacked training documentation |
| E41 | Certified Nursing Assistant | Lacked abuse, neglect and exploitation training documentation |
Inspection Report
Annual Inspection
Census: 93
Deficiencies: 21
Jul 25, 2022
Visit Reason
An unannounced Annual and Complaint Survey was conducted at the facility from July 12, 2022, through July 25, 2022, to assess compliance with applicable regulations and standards.
Findings
The survey identified multiple deficiencies related to personnel records, dementia training, tuberculosis screening, emergency preparedness, drug testing, reporting of alleged violations, accuracy of assessments, care planning, infection control, and other regulatory requirements. The facility failed to meet several regulatory requirements, affecting resident care and safety.
Severity Breakdown
SS=D: 6
SS=G: 1
SS=E: 1
SS=F: 1
Deficiencies (21)
| Description | Severity |
|---|---|
| Personnel records lacked evidence of tuberculosis screening, criminal background checks, mandatory drug testing, and adult abuse registry checks for several employees. | — |
| Facility failed to ensure required dementia training was completed for certain staff members. | — |
| Facility failed to ensure employees met minimum pre-employment tuberculosis screening requirements. | — |
| Facility failed to ensure required emergency preparedness training was completed for certain staff members. | — |
| Facility failed to ensure fingerprinting and/or drug screening was completed for certain staff prior to employment. | — |
| Facility failed to report a significant injury of unknown source within the required timeframe. | SS=D |
| Facility failed to ensure resident self-determination rights were honored for one resident. | — |
| Facility failed to ensure accuracy of assessments for residents, including medication and therapy evaluations. | SS=D |
| Facility failed to develop and implement comprehensive person-centered care plans for residents. | SS=D |
| Facility failed to develop and implement a hearing deficit care plan for a resident. | — |
| Facility failed to ensure proper treatment and prevention of pressure ulcers for certain residents. | SS=G |
| Facility failed to ensure residents were free of significant medication errors. | SS=D |
| Facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. | SS=E |
| Facility failed to ensure infection prevention and control program was established and maintained. | SS=F |
| Facility failed to provide and maintain proper abuse, neglect, and exploitation training for staff. | SS=D |
| Facility failed to ensure proper ventilation and airflow in laundry and linen rooms. | — |
| Facility failed to ensure proper hand hygiene and cleaning of glucometers during medication administration. | — |
| Facility failed to ensure soap dispensers were properly placed and functioning. | — |
| Facility failed to ensure proper documentation and follow-up of resident care, including wound care, dental services, and discharge summaries. | — |
| Facility failed to ensure proper care planning and implementation for residents with hearing loss, pressure ulcers, and other conditions. | — |
| Facility failed to ensure staff received required training and education on abuse, neglect, and exploitation. | — |
Report Facts
Facility census: 93
Survey sample: 42
Employees reviewed: 22
Staff sampled: 22
Residents investigated: 3
Residents sampled: 4
Residents reviewed: 29
Residents reviewed: 5
Residents reviewed: 2
Residents reviewed: 2
Residents reviewed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E35 | Agency CNA | Missing evidence of tuberculosis screening and adult abuse registry check |
| E36 | LPN | Missing evidence of recent chest x-ray for tuberculosis screening |
| E38 | Agency LPN | Missing evidence of adult abuse registry check and mandatory drug test |
| E39 | LPN | Missing evidence of determination letter from State agency in lieu of criminal background check |
| E40 | Agency CNA | Missing evidence of mandatory drug testing and adult abuse registry check |
| E41 | Agency CNA | Missing evidence of chest x-ray and tuberculosis skin test |
| E9 | Occupational Therapist | Missing drug test result and fingerprinting for pre-employment background check |
| E37 | Occupational Therapist | Missing drug test result and fingerprinting for pre-employment background check |
| E38 | Agency Licensed Practical Nurse | Missing drug test result and fingerprinting for pre-employment background check |
| E40 | Agency Certified Nurse Assistant | Missing drug test result and fingerprinting for pre-employment background check |
| E42 | HR | Provided statements regarding missing documentation for multiple employees |
| E1 | NHA | Reviewed findings and participated in exit conferences |
| E2 | DON | Reviewed findings and participated in exit conferences |
| E16 | Licensed Practical Nurse, Unit Manager | Confirmed findings related to resident bathing preferences |
| E15 | Minimum Data Set Coordinator | Confirmed findings related to therapy evaluations and care plans |
| E8 | Social Worker | Confirmed findings related to PASARR screening and medication |
| E6 | Registered Dietician | Confirmed findings related to nutritional adequacy and meal observations |
| E7 | Dining Services | Confirmed findings related to meal service and food safety |
| E3 | ADON | Confirmed findings related to resident discharge and hearing aid needs |
| E23 | RN | Confirmed findings related to care plan and therapy documentation |
| E24 | CNA | Confirmed findings related to resident care and grooming |
| E9 | Occupational Therapist | Confirmed findings related to resident care and therapy |
| E28 | LPN | Observed medication administration and resident care |
| E18 | RN | Observed medication administration and resident care |
| E26 | NP | Documented wound care and resident progress notes |
| E14 | Wound Care Consultant Physician | Consulted on wound care for resident |
| E30 | CNA | Confirmed resident feeding and care |
| E29 | CNA | Confirmed resident feeding and care |
| E31 | NP | Documented resident progress and medication |
| E20 | RN | Confirmed resident care and documentation |
| E17 | Nurse Practitioner | Documented resident discharge and diagnoses |
| E10 | Certified Nurse's Aide | Confirmed resident care and intervention |
| E32 | Agency CNA | Involved in resident injury incident |
| E19 | LPN | Observed food service and resident care |
| E25 | RN | Confirmed resident care and documentation |
| E27 | LPN | Documented resident care and medication |
| E33 | LPN | Reviewed tuberculosis screening documentation |
| E34 | LPN | Reviewed tuberculosis screening documentation |
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 2
May 18, 2021
Visit Reason
An unannounced complaint survey was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection from May 12, 2021 to May 18, 2021.
Findings
The facility failed to provide respiratory care as ordered to one resident and failed to accurately document respiratory care for another resident. Additionally, the facility failed to safeguard resident-identifiable information in medical records.
Complaint Details
The complaint investigation found that the facility failed to provide respiratory care as ordered to resident R4 and failed to accurately document respiratory care for resident R8. The facility also failed to safeguard resident-identifiable information in medical records.
Severity Breakdown
SS=D: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide respiratory care, including tracheostomy care and suctioning, consistent with professional standards for one resident. | SS=D |
| Failure to maintain accurate and complete medical records for respiratory care for one resident. | SS=E |
Report Facts
Residents sampled: 8
Facility census: 96
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E3 NP | Nurse Practitioner | Physician order author for respiratory therapy and BiPAP fitting. |
| E2 DON | Director of Nursing | Confirmed Respiratory Therapist did not re-evaluate BiPAP fitting and participated in exit teleconference. |
| E1 NHA | Nursing Home Administrator | Participated in exit teleconference reviewing findings. |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 1
Feb 11, 2021
Visit Reason
An unannounced COVID-19 Focused Infection Control Survey and Complaint Survey was conducted by the State of Delaware Division of Health Care Quality from February 5, 2021 through February 11, 2021.
Findings
The facility failed to revise the care plan for one resident (R2) to address refusal of nail care, resulting in deficiencies related to comprehensive care plan requirements. The survey included review of clinical records and interviews.
Complaint Details
The visit was complaint-related and included a COVID-19 focused infection control survey. The complaint was substantiated as evidenced by the deficiency in care plan revision for resident R2.
Deficiencies (1)
| Description |
|---|
| Facility failed to revise resident R2's care plan on ADL care to address refusal of nail care. |
Report Facts
Residents in survey sample: 8
Facility census: 81
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator (NHA) | Participated in exit conference and confirmed findings |
| E3 | Assistant Director of Nursing (ADON) | Participated in exit conference |
| E4 | Certified Nurse's Aide (CNA) | Documented refusal of nail care |
Loading inspection reports...
