Inspection Reports for
Delaware Hospital for the Chronically Ill

The complaint investigation found that two residents were inadequately supervised. Resident R1, cognitively impaired and at high risk for elopement, left the facility unsupervised and was found 17-20 miles away. Resident R2, completely dependent, fell from bed during care and sustained a right femur fracture. The immediate jeopardy was called on 10/1/25 and abated on 10/2/25.

The facility failed to provide adequate supervision to prevent elopement and falls for two residents, resulting in immediate jeopardy to resident health and safety. One resident eloped from the facility and was found miles away, and another resident sustained a femur fracture after falling from bed during care.

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.

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.

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.

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.

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.

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.

The facility failed to ensure adequate hands-on assistance and supervision during a mechanical lift transfer for one resident, resulting in a fall causing severe head injuries and the resident's subsequent death. The facility implemented an abatement plan including staff training and care plan reviews.

This was a Recertification with Complaints survey conducted due to complaints. The facility was found not in compliance with emergency preparedness requirements.

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.

The facility was found deficient in multiple areas including failure to provide quarterly personal funds statements to residents or their representatives, delayed reporting of abuse allegations, inaccurate resident assessments, failure to refer for PASARR level II review, incomplete care plans for dialysis catheter monitoring, inadequate dialysis care, improper management of psychotropic medications, and unsanitary food storage and preparation practices.

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.

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.

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.

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.

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.

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.