Inspection Report Summary
The most recent inspection on January 21, 2026, found the facility to be in substantial compliance with no deficiencies noted. Earlier inspections showed a pattern of deficiencies primarily related to abuse prevention and reporting, care planning, staff training, and regulatory compliance in areas such as respiratory care and medication management. A substantiated complaint in November 2025 involved failure to prevent and report sexual abuse between residents, along with inadequate care plan updates and staff education. Prior complaint investigations and annual surveys also identified issues with infection control, dementia training, medication errors, and resident safety, but enforcement actions such as fines or license suspensions were not listed in the available reports. The inspection history suggests some improvement over time, culminating in the most recent follow-up survey confirming compliance.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
34% better than Delaware average
Delaware average: 8.8 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
52 residents
Based on a January 2026 inspection.
Census over time
Inspection Report
Follow-Up
Census: 52
Deficiencies: 0
Jan 21, 2026
Visit Reason
An unannounced follow-up survey was conducted to the complaint survey ending November 7, 2025, to assess compliance with regulatory requirements.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care as of November 21, 2025.
Report Facts
Sample size: 3
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 3
Nov 5, 2025
Visit Reason
An unannounced complaint survey was conducted from November 5 through November 7, 2025, to investigate allegations of abuse and neglect involving specific residents.
Findings
The facility failed to prevent sexual abuse between residents with cognitive impairments, failed to report abuse allegations within required timeframes, and did not properly update or implement care plans and staff education. Corrective actions included mandatory staff in-service training, revised care plans, and enhanced monitoring and reporting procedures.
Complaint Details
The complaint investigation was substantiated. The facility failed to prevent sexual abuse between residents (R1 and R2) and failed to report the abuse allegation within the required two-hour timeframe. The facility also failed to update care plans and educate staff adequately.
Deficiencies (3)
| Description |
|---|
| Failure to ensure a resident was free from sexual abuse resulting in psychosocial harm. |
| Failure to report allegations of abuse to the State Agency within two hours. |
| Failure to develop and implement comprehensive care plans within required timeframes. |
Report Facts
Residents involved in abuse: 3
Facility census: 51
Survey sample size: 3
BIMS scores: 7
BIMS scores: 8
BIMS score: 6
BIMS score: 99
Mandatory in-service date: Nov 14, 2025
Care plan development timeframe: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E4 | Certified Nurse Assistant (CNA) | Interviewed regarding resident redirection and behavior during abuse incidents. |
| E5 | Certified Nurse Assistant (CNA) | Interviewed regarding resident redirection and behavior during abuse incidents. |
| E6 | Certified Nurse Assistant (CNA) | Interviewed regarding resident separation and behavior after incidents. |
| E7 | Registered Nurse (RN) | Interviewed regarding observations and reporting of abuse incidents. |
| E2 | Director of Nursing (DON) | Confirmed care plan updates and oversight of monitoring and reporting. |
| E1 | Nursing Home Administrator (NHA) | Participated in exit conference reviewing findings. |
| E3 | Assistant Director of Nursing (ADON) | Participated in exit conference reviewing findings. |
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 11
Oct 6, 2025
Visit Reason
An unannounced Annual, Complaint and Emergency Preparedness Survey was conducted at the facility from October 1, 2025, through October 6, 2025.
Findings
The survey identified multiple deficiencies related to notification of changes, abuse reporting, comprehensive care plans, respiratory care, physician visits, unnecessary drugs, quality assessment, training requirements, and other regulatory compliance areas. Root causes often involved lack of staff education, inconsistent monitoring, and inadequate documentation.
Complaint Details
The survey included complaint investigations related to failure to notify physician of critical changes, failure to report abuse allegations timely, and failure to provide respiratory care per standards. Some residents and employees were impacted and unable to correct the deficiencies.
Deficiencies (11)
| Description |
|---|
| Failure to immediately inform resident, physician, and resident representative of significant changes in condition. |
| Failure to report allegations of abuse to the State Agency within required timeframes. |
| Failure to develop a comprehensive person-centered care plan for an identified care area. |
| Failure to provide respiratory care per professional standards including labeling and changing CPAP tubing. |
| Failure to ensure physician reviewed the resident's total program of care at each visit. |
| Failure to ensure residents' drug regimens were free from unnecessary drugs and adequately monitored. |
| Failure to maintain a quality assessment and assurance committee with required documentation. |
| Failure to ensure required in-service training for nurse aides was completed. |
| Failure to ensure attendance at quarterly quality assurance and performance improvement meetings. |
| Failure to comply with Delaware Food Code in kitchen and food storage areas. |
| Failure to complete required pre-employment drug screening for employees. |
Report Facts
Residents present: 51
Survey sample: 13
Completion dates: 11
Heart rate bpm: 40
Bruise size cm: 2
Bruise size cm: 3.5
Training hours: 3
Drug screening penalty: 1000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Director of Nursing (DON) | Responsible for monitoring, education, and corrective actions related to multiple deficiencies |
| E3 | Assistant Director of Nursing (ADON) | Participated in exit conferences and education |
| E1 | Nursing Home Administrator (NHA) | Participated in exit conferences and responsible for oversight |
| E5 | Licensed Practical Nurse (LPN) | Confirmed CPAP tubing change practices |
| E8 | Registered Nurse (RN) | Confirmed heart rate monitoring and documentation |
| E10 | Medical Doctor (MD) | Confirmed expectations for notification of critical heart rates |
| E11 | Nurse Practitioner (NP) | Confirmed expectations for notification of critical heart rates |
| E14 | Certified Nursing Assistant (CNA) | Had incomplete in-service training hours |
| E15 | Certified Nursing Assistant (CNA) | Had incomplete in-service training hours |
| E16 | Certified Nursing Assistant (CNA) | Had incomplete in-service training hours |
| E17 | Certified Nursing Assistant (CNA) | Had incomplete in-service training hours |
| E18 | Certified Nursing Assistant (CNA) | Had incomplete in-service training hours |
| E19 | Certified Nursing Assistant (CNA) | Failed to complete required pre-employment drug screening |
| E20 | Human Resources (HR) | Confirmed drug screening administration and monitoring |
Inspection Report
Annual Inspection
Census: 53
Deficiencies: 5
Aug 21, 2024
Visit Reason
An unannounced Annual, Complaint and Emergency Preparedness Survey was conducted at the facility from August 21, 2024, through August 26, 2024.
Findings
The survey identified deficiencies including lack of dementia training for some employees, failure to complete comprehensive resident assessments and care plans within required timeframes, and medication administration errors resulting in a resident being sent to the emergency room. Corrective actions and plans for improvement were documented.
Complaint Details
The survey included complaint investigation components as deficiencies were identified related to dementia training, resident assessments, care planning, and medication administration.
Deficiencies (5)
| Description |
|---|
| Two out of five sampled employees lacked evidence of dementia training. |
| One out of fifteen residents failed to have a comprehensive assessment completed within 14 days of admission. |
| One out of eighteen residents failed to have a comprehensive care plan developed within 7 days of assessment completion. |
| One resident received incorrect insulin resulting in emergency room transport. |
| Facility failed to ensure timely tuberculosis testing for employees. |
Report Facts
Residents in survey sample: 18
Employees in survey sample: 5
Resident census: 53
Date range of survey: August 21, 2024 through August 26, 2024
Abatement date for medication deficiency: March 9, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Timothy Yoder | NHA | Provider's signature on report pages |
| E1 | Admin | Interviewed regarding dementia training and resident assessments |
| E2 | DON | Director of Nursing interviewed regarding dementia training, care plans, and medication administration |
| E5 | Admin Assistant | Interviewed regarding dementia training and TB testing |
| E7 | RN | Received medication education and involved in medication error |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 1
Sep 16, 2021
Visit Reason
An unannounced Focused Infection Control and Complaint survey was conducted at the facility on September 16, 2021, to assess compliance with infection control regulations and investigate a complaint.
Findings
The facility failed to follow CDC guidance for the use of PPE, specifically disposable gowns, which were found hanging used and contaminated in the COVID-19 unit. Staff education and corrective actions were implemented during the survey.
Complaint Details
The survey was triggered by a complaint and focused on infection control practices related to PPE use in the COVID-19 unit. The complaint was substantiated based on observations and interviews.
Deficiencies (1)
| Description |
|---|
| Failure to follow CDC guidance for use of disposable gowns, which were found used and hanging in the COVID-19 unit, risking contamination. |
Report Facts
Census: 50
Sample size: 11
Staff sample size: 8
Used disposable gowns observed: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E3 | Assistant Nursing Home Administrator | Interviewed regarding PPE gown use and infection control practices |
| E4 | Infection Preventionist | Escorted surveyors and provided information about PPE gown use and infection control |
| E1 | Nursing Home Administrator | Participated in exit interview |
| E2 | Director of Nursing | Participated in exit interview |
Inspection Report
Annual Inspection
Census: 47
Deficiencies: 9
Feb 3, 2017
Visit Reason
An unannounced annual and complaint survey was conducted at this facility beginning January 31, 2017 and ending February 3, 2017.
Findings
The facility was found deficient in multiple areas including failure to post the State Survey Agency phone number, failure to report abuse allegations timely, inadequate training on abuse prevention, failure to provide care in a respectful and dignified manner, failure to adequately assess and manage pain, failure to prevent pressure ulcers, failure to ensure timely medication administration, failure to maintain infection control, failure to maintain resident call system, and failure to ensure safety and accessibility of bathrooms.
Complaint Details
Complaint investigation was incorporated into the annual survey. Findings related to abuse reporting and training were substantiated.
Deficiencies (9)
| Description |
|---|
| Facility failed to post the State Survey Agency phone number or hotline number to report abuse in a visible place to residents, visitors, and staff. |
| Facility failed to immediately report an allegation of abuse/mistreatment concerning one resident and failed to provide adequate staff training on abuse prevention. |
| Facility failed to provide care in a respectful and dignified manner related to urinary catheter drainage bags being uncovered during meals and staff entering rooms without knocking. |
| Facility failed to adequately assess and manage pain for residents, including documentation and reassessment. |
| Facility failed to prevent pressure ulcers and failed to complete comprehensive assessments and accurate reassessments of pressure ulcers. |
| Facility failed to ensure medications were administered as ordered and failed to ensure timely medication administration. |
| Facility failed to establish and maintain an infection prevention and control program and failed to provide required immunizations. |
| Facility failed to ensure resident call system was adequate and failed to ensure bathrooms were accessible and safe for residents. |
| Facility failed to ensure physicians' orders were signed within required timeframes and failed to ensure proper documentation and follow-up on urinary catheters. |
Report Facts
Residents present: 47
Survey sample size: 12
Dates of survey: January 31, 2017 to February 3, 2017
Date of survey completion: February 3, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E3 | Administrative Assistant | Confirmed abuse reporting findings and interviewee for multiple findings |
| E1 | Nursing Home Administrator (NHA) | Reviewed findings and participated in exit conference |
| E4 | Director of Nursing (DON) | Reviewed findings and participated in exit conference; involved in multiple interviews |
| E8 | Certified Nursing Assistant (CNA) | Involved in abuse incident with resident |
| E9 | Certified Nursing Assistant (CNA) | Observed slapping incident and reported to administration |
| E10 | Physician | Involved in medication order delays and signing |
| E11 | Assistant Nursing Home Administrator (Assistant NHA) | Confirmed findings related to posting of survey results |
| R6 | Resident | Subject of abuse allegation |
| R8 | Resident | Subject of urinary catheter and pressure ulcer findings |
| R9 | Resident | Subject of pressure ulcer and immunization findings |
| R10 | Resident | Subject of urinary catheter and medication order findings |
| R11 | Resident | Subject of urinary catheter and medication order findings |
| R12 | Resident | Subject of urinary catheter findings |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 6
Oct 25, 2013
Visit Reason
An unannounced complaint visit was conducted at the facility from October 25 through October 28, 2013, to investigate allegations related to resident care and facility compliance.
Findings
The facility failed to provide appropriate mental and psychosocial care to a resident who committed suicide during the survey period. Additionally, the facility failed to ensure the resident environment was free of accident hazards, specifically failing to secure weapons, and failed to provide adequate supervision and psychosocial services. Other deficiencies included failure to have proper refund and prepayment policies, failure to have signed contracts for payment, and failure to complete inventories of residents' personal effects.
Complaint Details
The complaint investigation was substantiated. The resident (R1) committed suicide on 10/15/13 in his room at the facility. The investigation revealed multiple failures including lack of psychosocial care, failure to monitor and secure weapons, and failure to coordinate psychiatric care.
Deficiencies (6)
| Description |
|---|
| Failure to provide mental and psychosocial care and services to a resident who committed suicide. |
| Failure to ensure the resident environment was free of accident hazards, including failure to secure weapons. |
| Failure to provide adequate supervision to prevent accidents for one resident. |
| Failure to provide a refund and prepayment policy at the time of admission. |
| Failure to have a signed contract for facility payment from the resident at the time of admission. |
| Failure to complete an inventory of resident's personal effects upon admission. |
Report Facts
Resident census: 56
Sample size: 11
Resident suicide date: Oct 15, 2013
Number of guns found: 2
Medication dosage: 0.5
Depression scale score: 8
Depression scale questions: 15
Depression scale threshold: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Administrator | Interviewed during investigation; aware of resident's suicidal tendencies and gun possession. |
| E2 | Director of Nursing | Interviewed; confirmed lack of policy for depression assessment and hospice plans. |
| E5 | Registered Nurse | Documented late entry and witnessed resident's body after suicide. |
| E8 | Hospice Social Worker | Present during conversations with resident; provided hospice psychosocial assessments. |
| E4 | Administrative Assistant | Confirmed failure to provide refund/prepayment policy and contract signatures. |
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