Inspection Reports for Delaware Oaks Center for Rehabilitation and Nursing

The complaint investigation (2598732) found that Resident #51 touched Resident #12 inappropriately without consent. Multiple witnesses including Resident #61 and Certified Nurse Aides reported the incident. The facility's investigation confirmed reasonable cause to believe abuse occurred. The abuse allegation was not reported to the State Agency within the required two-hour timeframe.

The facility failed to protect residents from resident-to-resident sexual abuse involving Resident #51 and Resident #12, both severely cognitively impaired and unable to consent. Additionally, the facility did not timely report the abuse allegation to the State Agency within the required timeframe.

One isolated infection prevention & control deficiency with no actual harm but potential for minor harm, corrected by May 15, 2025.

The complaint investigation (#NY000373627) found that staff did not wear gowns as required for enhanced barrier precautions during care of Resident #1. Interviews revealed some staff were unaware or did not notice the precautions, and the Director of Nursing confirmed the requirement for gowns and gloves during direct hands-on care to prevent infection transmission.

The facility failed to ensure staff compliance with enhanced barrier precautions, specifically the use of gowns during hands-on care activities for Resident #1, who had wounds requiring such precautions. Staff were observed not wearing gowns despite posted signage and care requirements, posing a risk for transmission of infections.

Multiple isolated and widespread standard health deficiencies including care plan, abuse prevention, mobility, pest control, physical environment, resident allergies, restraints, environment, pressure ulcer treatment; and life safety code deficiencies related to building construction, doors, electrical systems, fire alarm, gas equipment, hazardous areas, illumination, maintenance, sprinkler system, and smoke barriers. All corrected by October 7, 2024.

The complaints investigated included issues with housekeeping and maintenance services (Complaint #NY00336247 and #NY00319578), resident abuse (Complaint #NY00330109), care plan implementation (Complaint NY00345819), and dietary accommodations (Complaint #NY00330919). The resident-to-resident abuse was substantiated with incidents involving Resident #72 and Resident #61, including minor injuries and inadequate preventive interventions.

The facility failed to maintain a safe, clean, and homelike environment due to roof leaks, disrepair of walls, floors, and ceilings, and strong urine odors. Resident-to-resident abuse occurred due to inadequate interventions such as missing stop signs. The facility also failed to implement person-centered care plans fully and did not consistently accommodate resident dietary preferences, serving meat to a vegetarian resident.

The complaint investigations included issues of housekeeping and maintenance deficiencies, resident abuse, restraint misuse, incomplete care plans, wound care neglect, range of motion treatment failures, dietary preference violations, and pest infestations.

The facility was found deficient in maintaining a safe, clean, and homelike environment with issues including leaking roof and water damage, resident-to-resident abuse incidents without proper interventions, improper use of restraints, incomplete care plans, failure to implement wound care recommendations, inadequate contracture management, failure to accommodate dietary preferences, and ineffective pest control resulting in flies and spiders in resident areas.

Multiple standard health deficiencies including food sanitation, abuse prevention, psychotropic medication use, physical environment, reporting violations, resident call system, and life safety code deficiencies including hand rub dispensers, building construction, doors, electrical systems, elevators, fire alarm, gas equipment, hazardous areas, means of egress, portable heaters, sprinkler system. All corrected by May 12, 2023.

The complaint investigation involved allegations of sexual abuse between residents #1, 21, 67, and 246. The incidents were substantiated as abuse by facility staff and administration. The facility did not report the abuse to the State Survey Agency within the required 2-hour timeframe.

The facility failed to ensure residents were free from sexual abuse involving four residents. Specific incidents included Resident #246 engaging in non-consensual sexual contact with Resident #1, and Resident #67 touching Resident #21 inappropriately. The facility also failed to timely report the alleged abuse to the New York State Department of Health within the required 2-hour timeframe.

Complaint investigation #NY00298668 focused on allegations of sexual abuse involving residents #1, 21, 67, and 246. The investigation confirmed incidents of non-consensual sexual contact between residents and found failures in abuse prevention and reporting.

The facility was found to have failed to protect residents from sexual abuse involving multiple residents, failed to timely report alleged abuse to the state authorities, improperly restarted an antipsychotic medication without proper documentation or monitoring, had significant food safety and sanitation violations in the kitchen and nourishment areas, and had a non-functioning resident call bell system on the 2nd floor affecting multiple residents.

Standard health deficiency for essential equipment safe operating condition and life safety code deficiencies including electrical systems, fire alarm system out of service, and sprinkler system out of service. All corrected by February 17, 2023.

Isolated quality of care deficiency with actual harm (Level 3), corrected by July 8, 2022.

Isolated reporting of alleged violations deficiency (Level 2), corrected by May 1, 2022.

Isolated infection prevention & control deficiency (Level 2), corrected by December 17, 2021.

The facility was found deficient in multiple areas including failure to ensure resident dignity and privacy, inadequate pressure ulcer care and documentation, improper dialysis care communication and dressing management, lack of physician documentation for continued use of PRN psychotropic medication beyond 14 days, and unsafe medication storage practices including unlocked medication rooms, expired medications, undated insulin pens, and improperly stored discontinued controlled substances.