Inspection Reports for Coral Springs Rehabilitation and Healthcare Center
DE, 19808
Back to Facility ProfileDeficiencies per Year
20
15
10
5
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Follow-Up
Census: 153
Deficiencies: 0
Feb 7, 2025
Visit Reason
An unannounced Follow-Up Survey to the Annual and Complaint Survey ending November 15, 2024, was conducted at this facility from February 6, 2025, through February 7, 2025.
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 January 2, 2025. No deficiencies were identified at the time of the survey.
Report Facts
Survey sample size: 25
Inspection Report
Annual Inspection
Census: 153
Deficiencies: 17
Nov 15, 2024
Visit Reason
An unannounced annual and complaint survey was conducted at Springs Rehabilitation at Brandywine LLC from October 28, 2024, through November 15, 2024, to assess compliance with federal and state regulations for skilled and intermediate care nursing facilities.
Findings
The facility was found to have multiple deficiencies including failure to provide residents with updated resident rights, inadequate nursing staffing levels on some days, failure to treat residents with respect and dignity, incomplete admission and discharge notifications, inadequate care planning, and issues with environmental cleanliness and safety. Root causes often involved lack of staff understanding or failure to follow policies. Plans of correction were submitted with targeted completion dates.
Deficiencies (17)
| Description |
|---|
| Failure to provide updated resident rights to all residents both orally and in writing. |
| Failure to provide minimum nursing staffing levels of 3.28 hours of direct care per resident on four out of 39 days reviewed. |
| Failure to ensure residents were treated with respect and dignity, including improper handling of Foley catheter bags and lack of supervision during meals. |
| Failure to provide timely and proper notification of transfer or discharge to residents and responsible parties. |
| Failure to develop and implement comprehensive, person-centered care plans including baseline care plans and plans for residents with seizures and other conditions. |
| Failure to maintain a safe, clean, comfortable, and homelike environment, including dirty floors, broken fixtures, and inadequate linen supply. |
| Failure to properly assess and manage pain for residents with cognitive impairment. |
| Failure to thoroughly investigate and report alleged abuse and neglect incidents in a timely manner. |
| Failure to ensure residents receiving dialysis had proper care plans and laboratory results reviewed. |
| Failure to properly assess and monitor residents for risk of entrapment and to install and maintain bed rails safely. |
| Failure to ensure sufficient qualified staff in food service and to provide food that meets residents' preferences and dietary needs. |
| Failure to ensure residents' bowel and bladder continence care and protocols were properly implemented and monitored. |
| Failure to provide adequate care and pain management for residents with wounds and pressure injuries. |
| Failure to develop and implement care plans for residents with seizure disorders and other complex conditions. |
| Failure to ensure proper admission assessments and care planning for residents with mental health diagnoses. |
| Failure to maintain accurate and complete documentation of care and assessments. |
| Failure to ensure proper supervision and care during resident activities and outdoor access. |
Report Facts
Facility census: 153
Investigative sample: 91
Days reviewed for staffing compliance: 39
Days with insufficient staffing: 4
Residents reviewed for respect and dignity: 5
Residents reviewed for admission/discharge notification: 4
Residents reviewed for care plan accuracy: 6
Residents reviewed for pain management: 1
Residents reviewed for falls care plan: 5
Residents reviewed for bowel and bladder continence: 3
Residents reviewed for wound care: 1
Residents reviewed for seizure care plan: 1
Residents reviewed for admission assessments: 1
Residents reviewed for bed rail care plan: 7
Residents reviewed for food preferences: 13
Residents reviewed for bowel protocol: 1
Residents reviewed for dialysis care: 1
Residents reviewed for pain management: 1
Residents reviewed for admission assessments: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna P. Amos | Administrator | Named as provider's signature on multiple pages related to plan of correction and findings |
| E14 | Nursing Assistant | Interviewed regarding resident rights document awareness |
| E1 | Nursing Home Administrator | Interviewed and involved in review of findings and plan of correction |
| E2 | Director of Nursing | Interviewed and involved in review of findings and plan of correction |
| E47 | Regional Clinical Coordinator | Interviewed and involved in review of findings and plan of correction |
| E58 | Registered Dietitian | Interviewed and involved in review of findings and plan of correction |
| E53 | Certified Nursing Assistant | Observed during survey for resident care |
| E25 | Certified Nursing Assistant | Interviewed regarding resident care |
| E26 | Licensed Practical Nurse | Interviewed regarding resident care |
| E16 | Activities Director | Interviewed regarding resident activities and care plans |
| E55 | Regional Clinical Coordinator | Interviewed regarding resident care |
| E27 | Assistant Director of Nursing | Interviewed regarding resident care |
| E4 | Licensed Practical Nurse/Quality Assurance/Infection Preventionist | Interviewed regarding resident care |
| E54 | Registered Nurse | Interviewed regarding resident care |
| E62 | Licensed Practical Nurse/Unit Manager | Interviewed regarding admission assessments |
| E66 | Rehab Director | Interviewed regarding bed rails and rehabilitation |
| E18 | Environmental Services Director | Interviewed regarding environmental cleanliness |
| E23 | Certified Nursing Assistant | Interviewed regarding linen supply |
| E31 | Registered Dietitian | Interviewed regarding food service |
| E37 | Activities Staff | Interviewed regarding resident activities |
| E56 | Licensed Practical Nurse | Interviewed regarding food service |
| E8 | Dietary Supervisor | Interviewed regarding food service |
| E70 | Kitchen Cook | Interviewed regarding food service |
| E33 | Regional Dietary Consultant | Interviewed regarding food service |
| E21 | Registered Nurse/Unit Manager | Interviewed regarding bed rails and admission assessments |
| E24 | Licensed Practical Nurse | Interviewed regarding falls assessments |
| E54 | Registered Nurse | Interviewed regarding wound care |
| E52 | Nurse Practitioner | Interviewed regarding wound care |
| E2 | Director of Nursing | Interviewed regarding multiple findings |
| E57 | Registered Nurse Assessment Coordinator | Interviewed regarding assessments and care plans |
| E58 | Registered Dietitian | Interviewed regarding care plans |
| E41 | Nurse | Interviewed regarding pain management |
| E66 | Rehab Director | Interviewed regarding bed rails and rehabilitation |
Inspection Report
Annual Inspection
Deficiencies: 8
Nov 15, 2024
Visit Reason
The inspection was conducted as an annual survey of Springs Rehabilitation at Brandywine to assess compliance with federal regulations and standards for nursing facilities.
Findings
The facility was found deficient in multiple areas including food and drink provision, meal/snack frequency, food safety and sanitation, resident records confidentiality and accuracy, infection prevention and control, antibiotic stewardship, and COVID-19 immunization documentation. Deficiencies were discussed with facility leadership and plans of correction were outlined.
Severity Breakdown
SS=E: 6
SS=D: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility failed to provide each resident with drinks consistent with their needs and preferences. | SS=E |
| Facility failed to ensure residents received evening snacks as required. | SS=D |
| Facility failed to ensure food items were stored and prepared under sanitary conditions. | SS=E |
| Facility failed to maintain complete, accurate, and readily accessible resident medical records. | SS=E |
| Facility failed to establish and maintain an infection prevention and control program. | SS=E |
| Facility failed to ensure an antibiotic stewardship program was implemented. | SS=E |
| Facility failed to ensure residents received influenza and pneumococcal immunizations or documentation thereof. | SS=E |
| Facility failed to ensure residents received COVID-19 immunizations or documentation thereof. | SS=D |
Report Facts
Residents reviewed for food and drink deficiencies: 13
Residents reviewed for medical records deficiencies: 42
Residents reviewed for antibiotic stewardship: 21
Residents reviewed for influenza and pneumococcal immunizations: 8
Residents reviewed for COVID-19 immunizations: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E34 | Regional Dietary Consultant | Stated facility policy on coffee/tea provision and meal ticket accuracy. |
| E1 | NHA (Nursing Home Administrator) | Participated in findings review and discussions. |
| E2 | DON (Director of Nursing) | Participated in findings review and discussions. |
| E47 | Regional Clinical Consultant | Participated in findings review and discussions. |
| E8 | Dietary Supervisor | Confirmed breakdown in kitchen system regarding coffee/tea provision. |
| C1 | Consultant Pharmacist | Confirmed lack of medical diagnoses for anticoagulant therapy. |
| E4 | LPN/IP | Confirmed laboratory report upload issues and participated in interviews. |
| E15 | RN | Confirmed medication administration record deficiencies. |
| E26 | Surveyor | Observed infection control practices. |
| E69 | RN Night Shift Supervisor | Observed PPE use and infection prevention compliance. |
Inspection Report
Follow-Up
Census: 163
Deficiencies: 0
Jan 18, 2024
Visit Reason
An unannounced Follow-Up Survey to the Annual and Complaint Survey ending November 8, 2023, was conducted at the facility from January 15, 2024 through January 18, 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 January 18, 2024. No deficiencies were identified at the time of the survey.
Report Facts
Survey sample size: 28
Inspection Report
Annual Inspection
Census: 147
Deficiencies: 9
Nov 8, 2023
Visit Reason
An unannounced annual and complaint survey was conducted from 10/24/23 through 11/08/23 to assess compliance with 42 CFR 483 subpart B for Coral Springs Rehabilitation at Brandywine.
Findings
The facility was found not to be in substantial compliance with federal regulations. Deficiencies were identified related to resident care, documentation, and facility policies, including issues with cognitive assessments, advance directives, care planning, medication administration, and safety measures.
Deficiencies (9)
| Description |
|---|
| Facility failed to provide appropriate documentation of RSO's cognitive assessment or capacity determination. |
| Resident care plans were not consistently updated or implemented, including care for cognitive impairment and bathing assistance. |
| Facility failed to ensure residents' rights to make advance directives were consistently honored and documented. |
| Inadequate supervision and assistance to prevent resident elopement and wandering. |
| Failure to accurately document and monitor residents' continence status and toileting programs. |
| Inadequate assessment and care planning for residents with feeding tubes and respiratory needs. |
| Medication administration errors including failure to follow physician orders and improper storage of medications. |
| Failure to maintain a safe and homelike environment, including housekeeping and maintenance issues. |
| Failure to ensure adequate staff training and competency verification. |
Report Facts
Survey Census: 147
Sample Size: 38
Supplemental Residents: 67
Inspection Report
Annual Inspection
Deficiencies: 5
Nov 8, 2023
Visit Reason
The inspection was conducted as an annual survey of Springs Rehabilitation at Brandywine to assess compliance with Medicare and Medicaid regulations, including medication management, infection control, food safety, resident records, and equipment safety.
Findings
The survey identified multiple deficiencies including improper medication management with medications on hand without current orders, lapses in medication destruction protocols, food safety violations such as improper storage and thawing techniques, incomplete and inaccurate resident medical records, and infection control program deficiencies. The facility was required to implement corrective actions including staff education and process improvements.
Severity Breakdown
Severity D: 2
Severity E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Medications were found on hand with no current orders and improper medication destruction procedures. | — |
| Food safety violations including improper storage of cantaloupes and thawing of ham, and unclean food disposal. | — |
| Resident medical records were incomplete and inaccurate, lacking documentation for oxygen orders and surgical wound care. | Severity D |
| Infection prevention and control program was ineffective, with failures in hand hygiene, PPE use, and cleaning protocols. | Severity E |
| Mechanical and electrical patient care equipment was not maintained in safe operating condition due to broken refrigerator gaskets. | Severity D |
Report Facts
Date survey completed: Nov 8, 2023
Deficiency F761: Medication management deficiencies noted on multiple residents
Deficiency F812: Food procurement, storage, preparation, and sanitation deficiencies
Deficiency F842: Resident records - identifiable information and medical record accuracy
Deficiency F880: Infection prevention and control program deficiencies
Deficiency F908: Essential equipment safe operating condition deficiencies
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse RN10 | Named in medication error and drug diversion findings | |
| Licensed Practical Nurse LPN15 | Named in medication error and drug diversion findings | |
| Director of Nursing DON | Director of Nursing | Interviewed regarding medication destruction and drug diversion |
| Licensed Practical Nurse LPN26 | Named in medication error and drug diversion findings | |
| Food Service Director FSD | Food Service Director | Confirmed food safety findings and corrective actions |
| Licensed Practical Nurse LPN18 | Observed cleaning and infection control practices | |
| Registered Nurse RN14 | Observed infection control practices | |
| Licensed Practical Nurse LPN19 | Observed infection control practices | |
| Registered Nurse RN7 | Observed infection control practices |
Inspection Report
Complaint Investigation
Census: 169
Deficiencies: 0
Aug 28, 2019
Visit Reason
An unannounced complaint survey was conducted at Brandywine Nursing & Rehabilitation Center on August 28, 2019.
Findings
No deficiencies were identified during the complaint survey conducted on August 28, 2019.
Complaint Details
The complaint survey was unannounced and conducted on August 28, 2019. No deficiencies were cited at the time of the survey.
Report Facts
Survey sample size: 3
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