Inspection Reports for
Delaware Oaks Center for Rehabilitation and Nursing

The state logged 154 complaints about this facility; 14 led to on-site inspections. The facility received 185.2 complaints per 100 beds versus a statewide rate of 57.4, resulting in 13 citations from complaints.

Across 11 inspections, 6 had no citations while 5 resulted in 63 total citations, including 24 standard health and 39 Life Safety Code violations. The facility had 154 complaints with 14 on-site inspections and 6 enforcement actions totaling $40,000 in fines.

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.

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.

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.

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.

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.