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.

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.

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.

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.