Inspection Reports for
Coral Springs Rehabilitation and Healthcare Center
DE, 19808
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
25.6 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
191% worse than Delaware average
Delaware average: 8.8 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
91% occupied
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Dec 8, 2025
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements related to resident rights, abuse reporting, investigation, accident prevention, and overall facility safety.
Findings
The facility was found deficient in respecting a resident's right to refuse medication, timely reporting of abuse and injuries of unknown origin, thorough investigation of abuse allegations, and ensuring resident safety during mechanical lift transfers. Several residents were affected by these deficiencies, with minimal harm or potential for actual harm noted.
Deficiencies (4)
Failed to respect a resident's right to refuse a medication for 1 resident.
Failed to timely report allegations of abuse or injuries of unknown origin to the state survey agency for 3 residents.
Failed to thoroughly investigate an allegation of staff-to-resident physical and verbal abuse for 1 resident.
Failed to ensure residents were free from accident hazards related to inappropriate use of a mechanical lift for 1 resident.
Report Facts
Residents reviewed for choices: 7
Residents affected by abuse reporting deficiency: 3
Residents reviewed for abuse or injuries: 7
Residents reviewed for accidents: 10
Residents affected by mechanical lift accident: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #13 | Registered Nurse | Named in medication administration and refusal incident with Resident #181 |
| LPN #1 | Licensed Practical Nurse | Named in staff-to-resident abuse allegation involving Resident #185 |
| CNA #2 | Certified Nursing Assistant | Witness and reporter of abuse allegation involving Resident #185 |
| RN Supervisor #3 | Registered Nurse Supervisor | Received abuse report from CNA #2 and reported to DON |
| LPN Supervisor #4 | Licensed Practical Nurse Supervisor | Interviewed regarding bowel protocol and abuse investigation |
| LPN #14 | Licensed Practical Nurse | Reported injury of unknown origin and described bowel protocol |
| DON | Director of Nursing | Oversaw abuse investigations and described facility policies |
| Administrator | Facility Administrator | Provided statements on abuse reporting and investigation |
| LPN #7 | Licensed Practical Nurse | Interviewed regarding mechanical lift accident involving Resident #184 |
| CNA #8 | Certified Nursing Assistant | Involved in mechanical lift accident with Resident #184 |
Inspection Report
Deficiencies: 4
Date: Dec 8, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, abuse reporting and investigation, accident prevention, and safe resident handling at Springs Rehabilitation at Brandywine.
Findings
The facility was found deficient in respecting a resident's right to refuse medication, timely reporting and investigating allegations of abuse and injuries of unknown origin, and ensuring safe use of mechanical lifts to prevent resident accidents. Several residents were affected by these deficiencies, with substantiated abuse against a staff member and a resident fall due to improper use of a mechanical lift.
Deficiencies (4)
F 0550: The facility failed to respect Resident #181's right to refuse a medication, administering a bowel suppository despite the resident's refusal and prior bowel movements.
F 0609: The facility failed to timely report suspected abuse, neglect, or injuries of unknown origin to the state survey agency for Residents #67, #178, and #185.
F 0610: The facility failed to thoroughly investigate an allegation of staff-to-resident physical and verbal abuse involving Resident #185 and LPN #1, resulting in substantiated abuse and placement of LPN #1 on the Adult Abuse Registry.
F 0689: The facility failed to ensure Resident #184 was free from accident hazards related to improper use of a mechanical lift, resulting in a fall while being transferred by one staff member instead of two.
Report Facts
Residents reviewed for abuse or injuries: 7
Residents affected by abuse reporting deficiency: 3
Residents reviewed for accidents: 10
Residents affected by mechanical lift accident: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in substantiated abuse finding involving Resident #185 |
| RN #13 | Registered Nurse | Involved in medication administration to Resident #181 |
| CNA #2 | Certified Nursing Assistant | Witnessed and reported abuse involving Resident #185 and LPN #1 |
| RN Supervisor #3 | Registered Nurse Supervisor | Received abuse report from CNA #2 and reported to DON |
| LPN #14 | Licensed Practical Nurse | Reported injury of unknown origin for Resident #178 |
| LPN #7 | Licensed Practical Nurse | Interviewed regarding mechanical lift accident involving Resident #184 |
| CNA #8 | Certified Nursing Assistant | Involved in mechanical lift accident with Resident #184 |
| Director of Nursing | Director of Nursing | Provided statements on abuse investigations and mechanical lift procedures |
| Administrator | Administrator | Provided statements on abuse reporting and investigations |
Inspection Report
Follow-Up
Census: 153
Deficiencies: 0
Date: 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
Complaint Investigation
Deficiencies: 17
Date: Nov 15, 2024
Visit Reason
The inspection was conducted based on complaints and investigations related to resident care, safety, and regulatory compliance at Springs Rehabilitation at Brandywine.
Complaint Details
The visit was complaint-related, investigating multiple allegations including failure to provide Medicare notifications, inadequate care and treatment, failure to report abuse, improper discharge and transfer notifications, and other regulatory compliance issues.
Findings
The facility was found deficient in multiple areas including failure to provide required Medicare beneficiary notifications, inadequate housekeeping and maintenance, failure to timely report suspected abuse, incomplete investigations of injuries, failure to notify ombudsman of transfers, improper admission and post-fall assessments by unlicensed personnel, inadequate pain management, failure to collaborate with dialysis providers, food service deficiencies including lack of qualified food safety personnel and delayed meal deliveries, failure to provide drinks consistent with resident preferences, improper food storage, incomplete medical records, and inadequate antibiotic stewardship.
Deficiencies (17)
Failed to provide resident R159's responsible party with required Notice of Medicare Non-Coverage and option to appeal, resulting in out-of-pocket payment.
Failed to maintain a safe, clean, comfortable environment including adequate housekeeping, maintenance, and linen supply.
Failed to timely report suspected abuse and thoroughly investigate injuries of unknown origin for resident R14.
Failed to notify Ombudsman of resident R102's hospital transfer.
Failed to implement policy allowing resident R125 to return after hospitalization, resulting in unnecessary prolonged hospitalization.
Failed to ensure accurate Minimum Data Set (MDS) assessment for resident R158, omitting documentation of bipap use.
Failed to develop and implement individualized care plans for seizure disorder and bed rail usage for residents R41, R14, R67, and R76.
Failed to provide appropriate pain management for resident R157 prior to wound care, resulting in pain and harm.
Failed to ensure ongoing collaboration with dialysis center for resident R102 regarding dialysis labs.
Failed to ensure qualified food service personnel with valid Food Protection Manager certificates and timely meal delivery; breakfast trays not served within 45 minutes of scheduled time.
Failed to provide drinks consistent with resident needs and preferences for 9 residents on the B unit.
Failed to provide evening snacks consistently for residents R23 and R78.
Failed to ensure food and items were stored and prepared under sanitary conditions including uncovered food, food debris, and lack of paper towels at handwashing sink.
Failed to maintain complete, accurate, and readily accessible resident medical records for eleven residents including missing urine culture reports and inaccurate documentation.
Failed to ensure anticoagulation medications had adequate medical diagnoses as indications for use for multiple residents.
Failed to ensure initial admission and post-fall assessments were completed by Registered Nurses as required by state regulations for multiple residents.
Failed to implement an antibiotic stewardship program ensuring antibiotics were prescribed in accordance with recognized standards and properly documented for residents R147, R307, and R606.
Report Facts
Days of bowel protocol not initiated: 13
Number of residents with missing or incomplete medical records: 11
Number of residents with inadequate pain management: 1
Number of residents with missing individualized care plans for bed rails or seizure disorder: 4
Number of residents with unqualified personnel completing assessments: 5
Number of residents not provided drinks consistent with preferences: 9
Number of residents not provided evening snacks: 2
Number of residents reviewed for antibiotic stewardship: 21
Number of residents with inadequate antibiotic stewardship: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | NHA | Named in multiple findings including Medicare notification failure, housekeeping, abuse reporting, transfer notification, food service deficiencies, and antibiotic stewardship |
| E2 | DON | Named in multiple findings including Medicare notification failure, housekeeping, abuse reporting, transfer notification, food service deficiencies, and antibiotic stewardship |
| E4 | LPN/QA/IC | Named in findings related to abuse reporting, antibiotic stewardship, and assessments |
| E3 | MD | Named in findings related to pain management, antibiotic orders, and medical record reviews |
| E52 | NP | Named in findings related to pain management, antibiotic orders, and medical record reviews |
| E58 | RDO | Named in findings related to Medicare notification failure, housekeeping, transfer policy, pain management, and food service |
| E47 | RCC | Named in findings related to transfer notification, pain management, food service, and medical record reviews |
| E27 | ADON | Named in findings related to transfer notification, pain management, assessments, and medical record reviews |
| E24 | LPN | Named in findings related to post-fall assessments |
| E6 | LPN | Named in wound care progress note |
| E21 | RN | Named in bowel protocol and urine culture documentation |
| E22 | CNA | Named in bowel movement size interview |
| E23 | CNA | Named in bowel movement size interview |
| E55 | LPN | Named in admission assessments and antibiotic stewardship |
| E60 | LPN | Named in admission assessments |
| E61 | LPN | Named in admission assessments |
| E62 | LPN/UM | Named in admission assessments |
| E33 | Regional Dietary Consultant | Named in food service and meal delivery findings |
| E8 | Dietary Supervisor | Named in food service and meal delivery findings |
| E70 | Kitchen Cook | Named in food service findings for lack of food safety certification |
| E34 | Regional Dietary Consultant | Named in drink provision findings |
| E42 | CNA | Named in evening snack findings |
| E43 | CNA | Named in evening snack findings |
| E41 | CNA | Named in evening snack findings |
| E40 | RN | Named in food storage findings |
| E4 | LPN/IP | Named in antibiotic stewardship and urine culture documentation |
| E52 | NP | Named in antibiotic stewardship and pain management |
| E24 | LPN | Named in post-fall assessment findings |
| E15 | RN | Named in enteral feed water flush documentation |
| E60 | LPN | Named in admission assessments |
| E4 | LPN/IP | Named in urine culture documentation |
| E1 | NHA | Named in multiple findings including Medicare notification failure, housekeeping, abuse reporting, transfer notification, food service deficiencies, and antibiotic stewardship |
Inspection Report
Routine
Deficiencies: 23
Date: Nov 15, 2024
Visit Reason
Routine inspection of Springs Rehabilitation at Brandywine to assess compliance with healthcare regulations including resident care, infection control, medication management, and facility operations.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, care planning, infection control, medication administration, food service, and documentation. Several residents were not provided care according to their plans, infection control protocols were not consistently followed, and documentation was incomplete or inaccurate.
Deficiencies (23)
F557: The facility failed to ensure residents were treated with respect and dignity, including improper catheter bag placement visible from hallway.
F557: Staff observed sitting on cellphone and not assisting residents during lunch in dining room.
F561: The facility failed to allow cognitively intact residents the choice to go outside on their own or alone.
F577: The facility failed to have survey results from the past three years readily accessible to residents and families.
F584: The facility failed to maintain a safe, clean, comfortable environment including adequate linens and housekeeping.
F623: The facility failed to notify the Ombudsman of a resident's hospital transfer.
F644: The facility failed to notify the state PASARR authority of residents' new mental disorder diagnoses requiring evaluation.
F656: The facility failed to develop and implement individualized care plans for seizure disorder and bed rail usage with measurable objectives.
F657: The facility failed to review and revise residents' comprehensive care plans for activities, bed rails, and enhanced barrier precautions.
F658: The facility failed to meet professional standards by having LPNs complete admission and post-fall assessments instead of RNs.
F679: The facility failed to provide outdoor activities during appropriate weather based on residents' assessments and care plans.
F684: The facility failed to provide care and treatment according to orders, resulting in hospitalization for fecal disimpaction due to failure to monitor bowel movements.
F690: The facility failed to provide services and assistance to maintain bladder continence to the extent possible for a resident.
F697: The facility failed to provide appropriate pain management for a resident with extensive wounds, resulting in pain during wound care.
F700: The facility failed to assess, obtain informed consent, and document risks and benefits prior to installing bed rails for multiple residents.
F802: The facility failed to ensure a qualified person in charge was present during kitchen operation and failed to provide timely breakfast meals.
F805: The facility failed to ensure food was prepared in a form appropriate to resident needs, including serving mechanical soft diet to a resident prescribed regular texture food.
F806: The facility failed to accommodate food preferences and failed to provide coffee or tea with breakfast to multiple residents.
F809: The facility failed to provide drinks consistent with resident needs and preferences to multiple residents.
F812: The facility failed to store and prepare food under sanitary conditions including uncovered food, dirty dishwashing area, and unlabeled food items.
F842: The facility failed to maintain complete, accurate, and accessible resident medical records including missing urine culture results and incomplete documentation of anticoagulant indications.
F883: The facility failed to document influenza and pneumococcal vaccinations or declinations in resident medical records.
F887: The facility failed to document COVID-19 vaccination status in resident medical records for some residents.
Report Facts
Days without enhanced barrier precautions: 46
Days without enhanced barrier precautions: 103
Shifts without bowel protocol initiation: 13
Residents without coffee or tea at breakfast: 9
Residents without drinks consistent with needs: 10
Residents reviewed for bed rails: 7
Residents reviewed for infection control: 13
Residents reviewed for antibiotic stewardship: 21
Residents reviewed for vaccines: 8
Residents reviewed for COVID-19 vaccines: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | NHA | Reviewed findings with surveyors |
| E2 | DON | Reviewed findings with surveyors |
| E4 | LPN/QA/IP | Confirmed infection control and documentation issues |
| E47 | RCC | Reviewed findings with surveyors |
| E58 | RDO | Reviewed findings with surveyors |
| E66 | Rehab Director | Interviewed regarding bed rail assessments and documentation |
| E8 | Dietary Supervisor | Confirmed meal delivery delays and food service issues |
| E16 | Activities Director | Interviewed regarding outdoor activities and resident preferences |
| E52 | NP | Ordered antibiotics and reviewed wound care |
| E24 | LPN | Completed post fall assessment |
| E62 | LPN/UM | Completed admission assessments |
| E4 | Infection Preventionist | Confirmed vaccination documentation issues |
Inspection Report
Annual Inspection
Census: 153
Deficiencies: 17
Date: 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)
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: 18
Date: Nov 15, 2024
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements for nursing home care and facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide required Medicare non-coverage notices, inadequate housekeeping and maintenance, failure to timely report and investigate injuries, incomplete and inaccurate resident assessments and care plans, inadequate pain management, insufficient dietary services and food safety practices, failure to maintain complete medical records, and deficiencies in antibiotic stewardship.
Deficiencies (18)
F0582: The facility failed to provide the required Notice of Medicare Non-Coverage and appeal options to a resident's responsible party, resulting in out-of-pocket payment for care.
F0584: The facility failed to maintain a safe, clean, and homelike environment including inadequate housekeeping, maintenance issues, and insufficient linen supplies.
F0609: The facility failed to timely report an injury of unknown origin to the State Agency.
F0610: The facility failed to thoroughly investigate injuries of unknown origin, including a bruise under a resident's chin.
F0623: The facility failed to notify the Ombudsman of a resident's hospital transfer.
F0626: The facility failed to allow a resident to return after hospitalization due to lack of payor source and failed to issue a 30-day discharge notice.
F0641: The facility failed to ensure the accuracy of a resident's Minimum Data Set by omitting documentation of nightly bipap use.
F0655: The facility failed to provide a baseline care plan signed by the resident or representative.
F0656: The facility failed to develop and implement individualized care plans for seizure disorder and bed rail usage for several residents.
F0658: The facility failed to meet professional standards by allowing LPNs to complete admission and post-fall assessments required to be done by RNs.
F0684: The facility failed to provide appropriate treatment and care for a resident with constipation, resulting in hospitalization for fecal disimpaction.
F0697: The facility failed to provide adequate pain management and assessments for a resident with extensive wounds, resulting in pain during wound care.
F0698: The facility failed to ensure ongoing collaboration with a dialysis center to monitor dialysis labs for a resident.
F0802: The facility failed to ensure a qualified Food Protection Manager was present during kitchen operations and failed to provide timely breakfast meals.
F0807: The facility failed to provide coffee or tea beverages consistent with resident meal tickets for multiple residents.
F0812: The facility failed to store and prepare food under sanitary conditions including food debris, uncovered food, and unlabeled items.
F0842: The facility failed to maintain complete, accurate, and accessible resident medical records including missing urine culture results and inaccurate documentation of water flushes and incontinence care.
F0881: The facility failed to implement an effective antibiotic stewardship program ensuring antibiotics were prescribed according to recognized standards and properly documented.
Report Facts
Shifts without bowel movement: 26
Days of delayed bowel protocol: 13
Residents affected by missing coffee or tea: 9
Residents reviewed for antibiotic stewardship: 21
Residents reviewed for medical records: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator (NHA) | Named in multiple interviews confirming findings and deficiencies. |
| E2 | Director of Nursing (DON) | Named in multiple interviews confirming findings and deficiencies. |
| E4 | LPN/QA/Infection Preventionist | Interviewed regarding antibiotic stewardship and infection control. |
| E52 | Nurse Practitioner (NP) | Ordered pain medications and antibiotics; involved in wound care management. |
| E58 | Regional Director of Operations (RDO) | Participated in findings review and interviews. |
| E47 | Regional Clinical Consultant (RCC) | Participated in findings review and interviews. |
| E33 | Regional Dietary Consultant | Interviewed regarding dietary services and food safety. |
| E8 | Dietary Supervisor | Interviewed regarding meal delivery and food service deficiencies. |
Inspection Report
Follow-Up
Census: 163
Deficiencies: 0
Date: 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
Routine
Deficiencies: 16
Date: Nov 8, 2023
Visit Reason
Routine inspection of Springs Rehabilitation at Brandywine nursing home to assess compliance with healthcare regulations and resident care standards.
Findings
The facility was found deficient in multiple areas including resident rights, care planning, medication administration, infection control, environmental cleanliness, and equipment maintenance. Specific issues included failure to honor resident self-determination, inaccurate assessments, incomplete care plans, medication errors, improper infection control practices, and unsafe food storage.
Deficiencies (16)
F0561: The facility failed to honor residents' rights to self-determination by not assisting residents out of bed or providing showers as per their preferences.
F0578: The facility failed to ensure residents or their surrogates were provided written information about their right to formulate advance directives.
F0584: The facility failed to maintain a clean and homelike environment, with multiple resident rooms having dirty privacy curtains, unclean areas under beds, and broken fixtures.
F0641: The facility failed to ensure accurate assessments for residents, including inaccurate documentation of tobacco use and urinary continence.
F0646: The facility failed to notify appropriate authorities for a resident diagnosed with delusional disorder requiring PASARR Level II screening.
F0656: The facility failed to develop comprehensive, person-centered care plans for residents, including failure to identify dialysis access and congestive heart failure monitoring.
F0657: The facility failed to ensure residents or their representatives were invited to participate in care plan meetings.
F0689: The facility failed to provide adequate supervision to prevent elopement, resulting in a resident eloping and sustaining injury.
F0693: The facility failed to ensure proper care of gastrostomy tubes during medication administration, including failure to check tube placement, flush tubes properly, and use gravity method for medication administration.
F0695: The facility failed to maintain clean oxygen concentrator filters and failed to properly administer nebulizer treatments and supplemental oxygen.
F0729: The facility failed to ensure a certified nursing assistant was properly licensed to work in Delaware.
F0760: The facility failed to prevent significant medication errors by administering insulin late repeatedly over several months.
F0761: The facility failed to ensure expired and discontinued medications were removed from medication carts and failed to restrict access to medications to authorized personnel only.
F0812: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, including improper thawing of ham and unclean food disposal.
F0880: The facility failed to implement an effective infection prevention and control program, including improper cleaning of glucometers, improper use of PPE, and inadequate hand hygiene.
F0908: The facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition, including a refrigerator with broken door gaskets.
Report Facts
Late insulin administrations: 23
Late insulin administrations: 25
Late insulin administrations: 14
Late insulin administrations: 16
Late insulin administrations: 23
Late insulin administrations: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN10 | Registered Nurse | Entered facility off shift, accessed medications, wasted narcotics without proper witness |
| LPN14 | Licensed Practical Nurse | Failed to properly disinfect glucometer and improperly administered g-tube medications |
| LPN17 | Licensed Practical Nurse | Failed to check g-tube placement and improperly administered medications via push method |
| DON | Director of Nursing | Confirmed multiple findings including late insulin administration and medication cart issues |
| LPN18 | Licensed Practical Nurse | Failed to properly disinfect glucometer and left resident unattended during nebulizer treatment |
| LPN23 | Licensed Practical Nurse | Failed to check g-tube placement and improperly administered medications via push method |
| RN7 | Registered Nurse | Failed to don gown for resident on isolation and improperly doffed PPE |
| LPN19 | Licensed Practical Nurse | Discarded PPE improperly outside resident room |
| LPN22 | Licensed Practical Nurse | Continued with torn gloves during blood sugar check |
| RN5 | Registered Nurse | Confirmed resident on enhanced barrier precautions and PPE requirements |
Inspection Report
Annual Inspection
Census: 147
Deficiencies: 9
Date: 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)
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: 16
Date: Nov 8, 2023
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with healthcare regulations and resident care standards.
Findings
The facility was found deficient in multiple areas including resident rights and self-determination, nutrition and hydration management, care planning, medication administration, infection control, and safety supervision. Specific failures included inadequate shower provision, failure to consult physicians on significant weight loss, incomplete care plans, delayed insulin administration, improper medication storage and disposal, inadequate respiratory care, and lapses in infection prevention practices.
Deficiencies (16)
F0561: The facility failed to honor residents' rights to self-determination by not assisting residents out of bed or providing showers as per their preferences.
F0580: The facility failed to notify physicians of significant weight loss for a resident who lost 67.9 pounds over nine months.
F0584: The facility failed to maintain a clean and homelike environment, with multiple resident rooms observed to have dirty privacy curtains, unclean areas, and maintenance issues.
F0655: The facility failed to provide baseline care plan summaries to residents or their responsible parties upon admission.
F0656: The facility failed to develop and implement complete care plans addressing all resident needs, including dialysis access and congestive heart failure monitoring.
F0684: The facility failed to ensure timely follow-up appointments and diagnostic tests after hospital discharge for a resident.
F0689: The facility failed to provide adequate supervision to prevent elopement, resulting in a resident wandering off and sustaining injury.
F0690: The facility failed to provide appropriate catheter care and bladder continence management, resulting in inappropriate catheter size replacement and lack of toileting programs.
F0692: The facility failed to recognize and address a resident's hydration status, resulting in dehydration and hospitalization with critically high sodium levels.
F0693: The facility failed to ensure proper care of gastrostomy tubes during medication administration, including checking tube placement, flushing, and using gravity method for medication delivery.
F0695: The facility failed to maintain clean oxygen concentrator filters, properly administer nebulizer treatments, and ensure supplemental oxygen availability.
F0711: The facility failed to ensure that a resident's total program of care, including advanced directives, was reviewed by providers at admission.
F0760: The facility failed to prevent significant medication errors by administering insulin late repeatedly over several months.
F0761: The facility failed to ensure medications were properly labeled, stored, and removed when discontinued or expired, and failed to restrict medication access to authorized personnel.
F0842: The facility failed to maintain accurate medical records, including documentation of surgical wounds and supplemental oxygen orders.
F0880: The facility failed to implement an effective infection prevention and control program, including proper cleaning of multi-use glucometers, appropriate use of PPE, and hand hygiene.
Report Facts
Insulin administrations late: 23
Insulin administrations late: 25
Insulin administrations late: 14
Insulin administrations late: 16
Insulin administrations late: 23
Insulin administrations late: 21
Weight loss: 67.9
Serum sodium level: 165
Residents with expired/discontinued meds on carts: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN14 | Licensed Practical Nurse | Failed to check gastrostomy tube placement and proper medication administration technique |
| LPN17 | Licensed Practical Nurse | Failed to check gastrostomy tube placement and proper medication administration technique |
| RN10 | Registered Nurse | Unauthorized access to medications and unobserved medication wasting |
| LPN15 | Licensed Practical Nurse | Involved in medication cart access and medication wasting incident |
| DON | Director of Nursing | Confirmed multiple findings including late insulin administration and medication storage issues |
| NP | Nurse Practitioner | Documented care but unaware of late insulin administration |
| LPN18 | Licensed Practical Nurse | Failed to properly disinfect glucometer and PPE use |
| LPN19 | Licensed Practical Nurse | Improper PPE disposal and lack of compliance with enhanced barrier precautions |
| LPN23 | Licensed Practical Nurse | Failed to wear gown for enhanced barrier precautions and improper gastrostomy medication administration |
| RN8 | Registered Nurse | Observed oxygen saturation and resident refusal of oxygen mask |
| RN5 | Registered Nurse | Observed oxygen saturation and assisted with oxygen administration |
| LPN21 | Licensed Practical Nurse | Glove tear during blood sugar check |
| RN7 | Registered Nurse | Failed to don gown for resident on isolation during accucheck |
| LPN22 | Licensed Practical Nurse | Glove tear during blood sugar check and improper glucometer cleaning |
| RN3 | Registered Nurse | Observed unauthorized medication wasting by RN10 |
| LPN26 | Licensed Practical Nurse | Reported medication cart access incident involving RN10 |
Inspection Report
Annual Inspection
Census: 66
Deficiencies: 4
Date: May 6, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, dietary services, special equipment needs, and infection prevention and control at Springs Rehabilitation at Brandywine.
Findings
The facility was found deficient in providing oral care to a dependent resident, ensuring a resident received their preferred diet consistency, providing special eating equipment to prevent spills, and maintaining an effective infection prevention and control program including proper hand hygiene and equipment disinfection.
Deficiencies (4)
Failed to provide oral care to one resident (R46) who was totally dependent on staff.
Failed to ensure one resident (R107) received her preferred and requested diet consistency.
Failed to provide special eating equipment and utensils for one resident (R84) to prevent spilling drinks.
Failed to establish and maintain an infection prevention and control program; staff failed hand hygiene and cleaning/disinfecting blood glucose meters between residents; failed to change oxygen tubing and humidifier bottle weekly for resident R16.
Report Facts
Residents reviewed for ADL's: 5
Residents affected: 1
Residents reviewed for diet consistency: 66
Residents affected: 1
Residents reviewed for ADL's: 5
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E9 | CNA | Stated CNAs are not responsible for oral care on patients with tracheostomies |
| E8 | UM | Stated CNAs are responsible for oral care |
| E2 | DON | Confirmed deficient practice regarding oral care and special eating equipment; involved in exit interviews |
| E11 | RNAC | Confirmed deficient practice regarding oral care and special eating equipment; involved in exit interviews |
| E1 | NHA | Participated in exit conferences reviewing findings |
| E14 | ST (Speech Therapist) | Provided information on diet consistency and special eating equipment recommendations |
| E13 | OT | Verified diet communication slip and recommended special eating equipment |
| E5 | FSD (Food Service Director) | Discussed diet consistency findings and meal ticket updates |
| E7 | LPN | Observed failing to clean/disinfect blood glucose meter and perform hand hygiene |
| E6 | RN | Observed failing to disinfect blood glucose meter properly between residents |
| E4 | RN | Confirmed oxygen tubing and humidifier bottle were not changed weekly |
| E3 | ADON | Confirmed infection control deficiencies and participated in exit interviews |
| E10 | CNA | Provided information on resident profile and special eating equipment usage |
| E12 | LPN | Observed giving resident a drink without appropriate special cup |
| E18 | Dietician | Stated meal ticket should have been updated for diet consistency |
Inspection Report
Complaint Investigation
Census: 169
Deficiencies: 0
Date: Aug 28, 2019
Visit Reason
An unannounced complaint survey was conducted at Brandywine Nursing & Rehabilitation Center 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.
Findings
No deficiencies were identified during the complaint survey conducted on August 28, 2019.
Report Facts
Survey sample size: 3
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