Deficiencies per Year
32
24
16
8
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
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
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
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
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
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
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 |
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