Inspection Report Summary
The most recent inspection on December 3, 2025, found the facility to be in substantial compliance with no deficiencies at that time. Earlier inspections showed multiple deficiencies primarily related to resident supervision, including failures to prevent elopement and falls resulting in injury, as well as issues with emergency preparedness policies. Substantiated complaint investigations documented inadequate supervision during transfers and elopement risks, with one instance involving immediate jeopardy that was abated promptly. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history indicates improvement in compliance with recent surveys showing no deficiencies after prior issues.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% better than Delaware average
Delaware average: 8.8 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
76 residents
Based on a December 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Census: 76
Deficiencies: 0
Dec 3, 2025
Visit Reason
An unannounced Revisit Survey to the Complaint Survey ending October 3, 2025, was conducted at this facility on December 3, 2025.
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 17, 2025.
Complaint Details
The visit was a revisit to a complaint survey ending October 3, 2025.
Report Facts
Sample size: 6
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 2
Oct 3, 2025
Visit Reason
An unannounced complaint survey was conducted at Delaware Hospital for the Chronically Ill from September 30, 2025, through October 3, 2025, based on observations, interviews, record reviews, and other documentation.
Findings
The facility failed to provide adequate supervision and assistive devices to prevent accidents, specifically related to resident R1 who eloped from the building and was found walking on the highway. The facility also failed to ensure adequate supervision to prevent R2's fall with injury. Multiple deficiencies were documented related to elopement risk and fall prevention.
Complaint Details
The complaint investigation was substantiated as the facility failed to prevent elopement of resident R1 and failed to prevent a fall with injury for resident R2. The investigation included interviews, clinical record reviews, video recordings, and observations confirming the deficiencies.
Severity Breakdown
R1: 1
R2: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| The facility failed to provide adequate supervision or assistive devices to ensure that resident R1 did not exit the building unsupervised, resulting in elopement and immediate risk of harm. | R1 |
| The facility failed to ensure adequate supervision to prevent resident R2's fall with injury. | R2 |
Report Facts
Facility census: 74
Survey sample size: 3
1:1 supervision duration: 72
Number of unsecured windows: 8
Visual checks missed: 18
Residents at high risk for elopement: 8
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 1
Oct 3, 2025
Visit Reason
The inspection was conducted due to concerns about accident hazards and inadequate supervision to prevent accidents in the nursing home, specifically related to two residents who experienced serious incidents.
Findings
The facility failed to provide adequate supervision to prevent accidents for two residents: R1, who eloped from the building and was found 17-20 miles away, and R2, who sustained a right femur fracture after falling from bed during care. Immediate jeopardy was identified and abated after corrective actions including staff training, enhanced supervision, and environmental safety improvements.
Complaint Details
The complaint investigation found that for two residents (R1 and R2), the facility failed to provide adequate supervision to prevent accidents. R1 eloped from the facility and was found miles away, posing immediate risk of severe injury or death. R2 fell from bed during care and sustained a right femur fracture. Immediate jeopardy was called and later abated after corrective measures.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Residents on secured unit: 18
Residents identified at higher risk for elopement: 8
Opportunities for visual checks missed: 18
Immediate jeopardy abatement date: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | NHA | Confirmed findings and participated in exit conference |
| E2 | DON | Confirmed findings and participated in exit conference |
| E3 | ADON | Participated in exit conference |
| E5 | QA | Located resident R1 after elopement |
| E6 | CNA | Provided care to R2 during fall incident |
| E7 | CNA | Interviewed regarding supervision of R1 |
| E8 | CNA | Interviewed regarding last sighting of R1 |
| E13 | LPN | Interviewed regarding R1's whereabouts on day of elopement |
Inspection Report
Follow-Up
Census: 70
Deficiencies: 0
Mar 24, 2025
Visit Reason
An unannounced Follow-Up to a Complaint Survey ending February 24, 2025, was conducted at this facility on March 24, 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 March 24, 2025. No deficiencies were identified at the time of the survey.
Complaint Details
Follow-Up to a Complaint Survey ending February 24, 2025.
Report Facts
Survey sample size: 3
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 24, 2025
Visit Reason
The inspection was conducted due to a complaint investigation following a resident fall incident involving improper use of a mechanical lift, resulting in serious injury to the resident.
Findings
The facility failed to ensure adequate hands-on assistance and supervision during a mechanical lift transfer for one resident, resulting in a fall causing a subdural hematoma, scalp lacerations, and the resident's subsequent death. Immediate Jeopardy was called due to the severity of the incident.
Complaint Details
The investigation was triggered by a fall incident involving resident R1, who was cognitively impaired and dependent. The fall occurred during transfer with a mechanical lift when two staff members failed to provide the required two-person hands-on assistance. The resident sustained severe head injuries and expired at the hospital. Immediate Jeopardy was called and later abated after corrective actions.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure adequate hands-on assistance and supervision during mechanical lift transfer, resulting in resident fall and serious injury. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Residents Affected: 1
Laceration size: 9
Laceration size: 5
Time Immediate Jeopardy called: 1030
Time of fall: 1230
Time Immediate Jeopardy abated: 700
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E5 | CNA | Named in the fall incident and investigative statements regarding mechanical lift use |
| E4 | LPN | Named in the fall incident and investigative statements regarding mechanical lift use |
| E6 | NP | Documented clinical record of resident fall and injuries |
| R4 | LPN | Interviewed regarding the fall incident and mechanical lift use |
| E1 | NHA | Participated in exit conference reviewing findings |
| E2 | ADON | Participated in exit conference reviewing findings |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 1
Feb 24, 2025
Visit Reason
An unannounced complaint survey was conducted at the Delaware Hospital for the Chronically Ill from February 19, 2025, through February 24, 2025, based on observations, interviews, and clinical record reviews.
Findings
The facility failed to ensure adequate supervision and assistance during resident transfers, resulting in a resident sustaining a fall with serious injuries including a subdural hematoma and scalp lacerations. The facility was cited for not providing the recommended two-person hands-on assistance during a mechanical lift transfer.
Complaint Details
The complaint investigation was substantiated. The facility failed to provide adequate supervision and assistance to prevent a resident fall on 02/14/2025, which resulted in serious injury and hospitalization. Immediate Jeopardy was called on 02/20/2025 and was abated on 02/22/2025.
Severity Breakdown
Immediate Jeopardy (IJ): 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure that a cognitively impaired resident received adequate supervision and hands-on assistance during transfer, resulting in a fall causing a subdural hematoma and scalp lacerations. | Immediate Jeopardy (IJ) |
Report Facts
Residents reviewed: 3
Residents sampled: 4
Facility census: 69
Fall incident date: Feb 14, 2025
Immediate Jeopardy called: Feb 20, 2025
Immediate Jeopardy abated: Feb 22, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E5 | Certified Nurse's Aide (CNA) | Documented observations and interviews related to the resident fall and transfer |
| E4 | Licensed Practical Nurse (LPN) | Documented nursing progress notes and involved in resident care during fall incident |
| R4 | Licensed Practical Nurse (LPN) | Interviewed regarding resident transfer and fall |
| Nurse Trainer Educator III | Provided mandatory in-service training on mechanical lift use and two-person assistance | |
| E1 | Nursing Home Administrator (NHA) | Participated in exit conference |
| E2 | Assistant Director of Nursing (ADON) | Participated in exit conference |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 5
Dec 12, 2024
Visit Reason
A Recertification with Complaints 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 12/09/24 through 12/12/24.
Findings
The facility was found to be not in compliance with 42 CFR 483.73 related to emergency preparedness policies and procedures, including deficiencies in tracking staff and residents during emergencies, policies for evacuation and managing residents who refuse to evacuate, medical documentation systems, emergency officials contact information, and emergency preparedness training and testing.
Complaint Details
This was a Recertification with Complaints survey conducted due to complaints. The facility was found not in compliance with emergency preparedness requirements.
Severity Breakdown
SS=F: 3
SS=D: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| The facility failed to develop a policy and procedure for an adequate tracking system for residents and staff as part of its emergency plan. | SS=F |
| The facility failed to establish policies and procedures for managing residents who refuse to evacuate during emergencies. | SS=D |
| The facility failed to establish policies and procedures for a medical documentation system that preserves and protects confidential patient information during emergencies. | SS=D |
| The facility failed to maintain a communications plan with required authorities including essential contact information for emergency preparedness staff. | SS=F |
| The facility failed to develop and maintain an emergency preparedness training and testing program that required annual review and updates. | SS=F |
Report Facts
Survey Census: 73
Sample Size: 21
Supplemental Residents: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Hospital Director | Interviewed regarding emergency identification system and policies | |
| Risk Manager | Interviewed regarding emergency identification system, policies, and training | |
| Hospital Administrator | Interviewed regarding emergency preparedness policies and training |
Inspection Report
Annual Inspection
Deficiencies: 0
Dec 12, 2024
Visit Reason
The inspection was conducted as an annual survey of Delaware Hospital F/T Chronically Ill (Dhci) to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 0
Jun 18, 2024
Visit Reason
An unannounced complaint survey was conducted at the facility on June 18, 2024.
Findings
No deficient practice was identified during the survey.
Complaint Details
The survey was complaint-related and no deficient practice was identified, indicating no substantiated deficiencies.
Report Facts
Survey sample residents: 2
Inspection Report
Annual Inspection
Census: 74
Deficiencies: 0
Jan 10, 2024
Visit Reason
An unannounced annual and complaint survey was conducted at the facility from January 3, 2024 through January 10, 2024.
Findings
No deficiencies were identified at the time of the survey. 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 10, 2024.
Complaint Details
The survey included a complaint investigation component, but no deficiencies or substantiated complaints were identified.
Report Facts
Survey sample residents: 18
Inspection Report
Annual Inspection
Deficiencies: 0
Jan 10, 2024
Visit Reason
The inspection was conducted as an annual survey of the Delaware Hospital F/T Chronically Ill (Dhci) facility to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Census: 85
Deficiencies: 10
Feb 22, 2022
Visit Reason
An unannounced Annual, Complaint, and Emergency Preparedness survey was conducted at Delaware Hospital f/t Chronically Ill (DHCI) from February 14, 2022 through February 22, 2022.
Findings
The survey identified multiple deficiencies across various regulatory requirements including accounting and records, reporting of alleged violations, abuse investigations, accuracy of assessments, coordination of PASARR and assessments, development and implementation of comprehensive care plans, dialysis monitoring, psychotropic medication management, and food safety. Corrective actions and plans of correction were provided by the facility.
Complaint Details
The complaint investigation revealed failures in reporting and investigating abuse allegations timely and thoroughly for multiple residents. The facility failed to immediately report abuse allegations to the state survey agency and failed to investigate abuse allegations adequately. Corrective actions included staff education and policy revisions.
Severity Breakdown
SS=D: 8
SS=B: 1
SS=E: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Facility failed to provide quarterly statements of resident personal funds for two residents. | SS=D |
| Facility failed to immediately report allegations of abuse for two residents. | SS=D |
| Facility failed to thoroughly investigate an allegation of abuse for one resident. | SS=D |
| Facility failed to complete accurate MDS assessments for one resident with pressure wounds. | SS=B |
| Facility failed to refer one resident for PASARR level II review timely. | SS=D |
| Facility failed to develop and implement a comprehensive care plan for one resident to monitor dialysis catheter. | SS=D |
| Facility failed to monitor dialysis catheter and weights for one resident consistently. | SS=D |
| Facility failed to ensure psychotropic medications were given only when necessary and failed to complete Gradual Dose Reduction (GDR) for two residents. | SS=D |
| Facility failed to ensure psychotropic medication orders had specific duration for continued use for one resident. | SS=D |
| Facility failed to ensure food was stored, prepared, and served in a sanitary manner. | SS=E |
Report Facts
Residents reviewed for personal funds: 4
Residents reviewed for abuse: 2
Residents reviewed for pressure wounds: 2
Residents reviewed for PASARR: 1
Residents reviewed for dialysis: 1
Residents reviewed for psychotropic medications: 5
Unlabeled insulated lunch bags: 3
Unlabeled jars of chicken and beef base: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Geraldine Stewart | LTC Section Chief | Provider's signature on report cover page. |
| E9 | Financial Determination Administrator | Involved in personal funds statement review and findings. |
| E1 | Nursing Home Administrator | Involved in abuse reporting and exit conference. |
| E2 | Director of Nursing | Involved in abuse reporting and exit conference. |
| E11 | Charge Nurse | Interviewed regarding abuse incident. |
| E12 | RN Supervisor | Prepared incident report related to abuse. |
| E14 | Unit Manager | Confirmed care plan monitoring and dialysis catheter issues. |
| E25 | Food Service Supervisor | Interviewed regarding food safety deficiencies. |
| E6 | Registered Nurse Assessment Coordinator (RNAC) | Confirmed errors in wound care documentation. |
| E8 | Pharmacist | Interviewed regarding medication orders and monitoring. |
| E18 | Registered Nurse | Confirmed AIMs testing completion. |
Inspection Report
Annual Inspection
Deficiencies: 9
Feb 22, 2022
Visit Reason
The inspection was conducted as part of the annual licensing survey to assess compliance with regulatory requirements related to resident care, abuse reporting, medication management, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide quarterly personal funds statements to resident representatives, delayed reporting of abuse allegations, inadequate investigation of abuse, inaccurate resident assessments, failure to refer for PASARR level II review, incomplete care plans for dialysis catheter monitoring, failure to monitor dialysis weights, improper management of psychotropic medications, and unsanitary food storage practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 8
Level of Harm - Potential for minimal harm: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to provide quarterly personal funds statements to resident representatives for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report suspected abuse and report investigation results to proper authorities for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to immediately put measures in place to prevent further potential abuse and failed to thoroughly investigate an allegation of abuse for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete accurate MDS assessments for pressure wounds for one resident. | Level of Harm - Potential for minimal harm |
| Failed to refer a resident with new psychiatric diagnoses and antipsychotic medications for PASARR level II resident review. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to initiate a comprehensive care plan to monitor a resident's dialysis catheter. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to monitor dialysis catheter and consistently monitor pre and post dialysis weights for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement gradual dose reductions and non-pharmacological interventions for psychotropic medications, failed to monitor side effects, and failed to ensure PRN psychotropic medication had a specific duration for continued use for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food was stored, prepared, and served in a sanitary manner, including unlabeled food items and lack of garbage can near hand sink. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for personal funds statements: 4
Residents reviewed for abuse reporting: 2
Residents reviewed for abuse investigation: 2
Residents reviewed for pressure wounds: 2
Residents reviewed for PASARR: 1
Residents reviewed for dialysis care: 1
Residents reviewed for psychotropic medication: 5
Unlabeled food items observed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E9 | Financial Determination Administrator | Named in findings related to failure to send quarterly personal funds statements. |
| E1 | Nursing Home Administrator (NHA) | Participated in exit conferences and acknowledged findings. |
| E2 | Director of Nursing (DON) | Participated in exit conferences and acknowledged findings. |
| E11 | Charge Nurse | Confirmed abuse incident reporting and dialysis weight monitoring deficiencies. |
| E14 | Unit Manager | Confirmed lack of dialysis catheter monitoring and missing dialysis weights. |
| E18 | Registered Nurse (RN) | Confirmed lack of AIM's testing for psychotropic medication monitoring. |
| E25 | Food Service Supervisor | Confirmed unsanitary food storage observations. |
| E24 | Food Service Director | Confirmed unsanitary food storage observations. |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 4
Mar 10, 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 March 10, 2021 through March 16, 2021 to investigate allegations of mistreatment and compliance with regulatory requirements.
Findings
The facility failed to ensure that a resident was free from physical restraints used for staff convenience and failed to immediately report allegations of mistreatment. The facility also failed to provide required training on abuse, neglect, exploitation, and misappropriation of resident property to staff. Corrective actions and training plans were implemented.
Complaint Details
The complaint investigation found that the facility failed to immediately report an allegation of mistreatment of one resident (R3) and failed to ensure the resident was free from physical restraint tied to the bed for staff convenience. The facility was also found deficient in training staff on abuse, neglect, exploitation, and misappropriation of resident property.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure a resident was free from physical restraint used for staff convenience. | SS=D |
| Failure to immediately report allegations of mistreatment to the State Agency. | SS=D |
| Failure to provide required annual training on abuse, neglect, exploitation, and misappropriation of resident property to staff. | SS=D |
| Failure to review and revise a resident's care plan to address behaviors of placing hands in pants and getting feces on hands. | SS=D |
Report Facts
Facility census: 90
Survey sample size: 7
Deficiencies cited: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E7 | Certified Nurse Aide (CNA) | Named in findings related to mistreatment reporting and training deficiencies |
| E3 | Hospital Administrator | Confirmed facility awareness of allegations and participated in exit conference |
| E2 | Director of Nursing (DON) | Participated in exit conference and corrective action planning |
| E1 | Nursing Home Administrator (NHA) | Participated in exit conference and corrective action planning |
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 2
Jul 22, 2019
Visit Reason
An unannounced complaint survey was conducted at the facility from July 22, 2019 through July 24, 2019 to investigate allegations of verbal/emotional abuse by staff to residents.
Findings
The facility failed to immediately report an allegation of verbal/emotional abuse to the state survey agency for one resident out of three sampled. The facility also failed to prevent further potential abuse during an ongoing investigation and did not reassign staff accused of abuse promptly. The Nursing Home Administrator and QA Administrator implemented refresher training and updated policies to address these deficiencies.
Complaint Details
The complaint investigation found that the facility failed to immediately report an allegation of verbal/emotional abuse for one resident (R1) out of three sampled residents. The allegation could not be substantiated, but the facility did not report it within the required two-hour timeframe. The facility also failed to prevent further potential abuse during the investigation and did not reassign the accused staff promptly. Refresher training and policy updates were implemented.
Severity Breakdown
Level 3: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to immediately report an allegation of verbal/emotional abuse to the state survey agency within required timeframes. | Level 3 |
| Failure to prevent further potential abuse while an investigation was in progress. | Level 3 |
Report Facts
Residents sampled: 3
Facility census: 101
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator | Involved in investigation and findings confirmation |
| E2 | Director of Nursing | Involved in investigation and findings confirmation |
| E3 | Quality Assurance Administrator | Reported incident to DHCQ and involved in findings confirmation |
| E4 | Registered Nurse, Unit Manager | Prepared memos and documented family calls related to the allegation |
| E5 | Registered Nurse | Completed employee interview statement |
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