Inspection Reports for Delmar Nursing and Rehabilitation Center
101 Delaware Av enue Delmar, DE, 19940
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Follow-Up
Deficiencies: 0
Jan 22, 2026
Visit Reason
A desk review follow-up visit was conducted on January 22, 2026, to the annual and complaint visit ending December 5, 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 January 13, 2026.
Inspection Report
Routine
Deficiencies: 1
Oct 1, 2024
Visit Reason
A desk review staffing audit was conducted by the State of Delaware, Division of Health Care Quality, Office of Long-Term Care Residents Protection to assess compliance with minimum staffing levels for nursing services as required by Delaware Code.
Findings
The facility failed to maintain the minimum required direct care staffing level of 3.28 hours per resident per day on two of seven days reviewed, with PPD values of 3.23 and 3.10 on 08-11-2024 and 08-17-2024 respectively.
Deficiencies (1)
| Description |
|---|
| Failure to maintain the minimum PPD staffing requirement of 3.28 hours per resident per day on two days reviewed. |
Report Facts
PPD staffing level: 3.23
PPD staffing level: 3.1
Minimum required PPD staffing: 3.28
Days reviewed: 7
Days noncompliant: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator | Completed Facility Staffing Worksheets revealing deficient staffing levels |
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 4
Sep 26, 2024
Visit Reason
A Recertification and Complaint 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 to assess compliance with federal regulations.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified related to emergency preparedness training, accuracy of resident assessments, and food safety including inadequate management training and sanitation issues.
Complaint Details
The survey was a Recertification and Complaint survey. The facility was found not to be in substantial compliance. The failure to ensure all staff were trained in emergency preparedness had the potential to affect all 82 census residents and 119 staff. The complaint was substantiated based on record review and interviews.
Severity Breakdown
Level D: 1
Level F: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure all staff were trained in emergency preparedness, with no evidence of annual emergency preparedness training for certain staff. | — |
| Inaccurate Minimum Data Set (MDS) assessments, including failure to document serious mental illness diagnosis correctly. | Level D |
| Failure to employ a qualified Dietary Manager with appropriate competencies and skills, including lack of management training. | Level F |
| Food safety violations including inadequate plumbing and sanitation in the three-compartment sink, missing insulated dome plate covers, and poor cleaning schedules. | Level F |
Report Facts
Survey Census: 82
Sample Size: 23
Supplemental Residents: 7
Deficiencies cited: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Director of Maintenance | Reviewed current education related to emergency preparedness policies and procedures; involved in monitoring corrective measures |
| Staff Educator | Staff Educator | Reviewed current education related to emergency preparedness policies and procedures; responsible for tracking new hire and annual emergency preparedness training |
| Administrator | Administrator | Reviewed current education related to emergency preparedness policies and procedures; stated expectation that residents' MDS were accurate |
| MDS Coordinator | MDS Coordinator | Conducted full house audit for resident assessments; involved in inaccurate diagnosis documentation |
| Dietary Manager | Dietary Manager | Lacked management training necessary for food service director position; held ServSafe Food Handler certificate but lacked management training |
| Regional Corporate Consultant | Regional Corporate Consultant | Revealed lack of emergency preparedness annual training; verified lack of management training for Dietary Manager |
| Director of Nursing | Director of Nursing | Stated expectation that residents' MDS would accurately reflect current diagnoses |
Inspection Report
Follow-Up
Census: 71
Deficiencies: 0
Dec 28, 2023
Visit Reason
An unannounced Follow-Up Survey to the Annual and Complaint Survey ending October 6, 2023, was conducted at this facility from December 27, 2023 through December 28, 2023.
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 November 27, 2023. No deficiencies were identified at the time of the survey.
Report Facts
Survey sample size: 14
Inspection Report
Annual Inspection
Census: 71
Deficiencies: 8
Oct 6, 2023
Visit Reason
An unannounced annual, complaint, and emergency preparedness survey was conducted at Delmar Nursing and Rehab Center from September 29, 2023 through October 6, 2023. The survey included review of clinical records, interviews, and facility documentation.
Findings
The survey identified deficiencies related to tuberculosis screening of employees, PASARR screening coordination, comprehensive care plans, pressure ulcer prevention, respiratory care, medication regimen review, drug labeling and storage, and food procurement and sanitation. Corrective actions and monitoring plans were provided by the facility.
Severity Breakdown
SS=D: 5
SS=G: 1
SS=C: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility failed to ensure that four out of twelve employees received pre-employment tuberculosis screening. | — |
| Facility failed to ensure PASARR screening was completed for residents with new diagnoses of psychotic disorder. | SS=D |
| Facility failed to develop and implement comprehensive care plans reflecting residents' medical, nursing, and psychosocial needs. | SS=D |
| Facility failed to provide care to prevent pressure ulcers and to promote healing for residents with pressure ulcers. | SS=G |
| Facility failed to accurately assess and document dental status and oxygen use in care plans for residents. | SS=D |
| Facility failed to maintain monthly medication regimen review policies and procedures and timely reporting. | SS=C |
| Facility failed to store drugs and biologicals in locked compartments and maintain proper refrigerator temperature logs. | SS=D |
| Facility failed to maintain food safety and sanitation standards in food procurement and refuse disposal. | SS=D |
Report Facts
Survey sample size: 18
Employees reviewed for TB screening: 12
Employees failed TB screening: 4
Residents reviewed for PASARR: 3
Residents reviewed for care plans: 18
Residents reviewed for pressure ulcers: 2
Residents reviewed for ROM/mobility: 4
Residents reviewed for oxygen use: 1
Residents reviewed for medication regimen: 1
Residents reviewed for drug storage: 1
Residents reviewed for food sanitation: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Director of Nursing (DON) | Interviewed regarding tuberculosis screening and care plan deficiencies |
| E3 | Unit Manager | Interviewed regarding care plan and deficiency findings |
| E4 | Social Worker | Interviewed regarding PASARR screening deficiencies |
| E6 | Unit Manager | Interviewed regarding pressure ulcer care and monitoring |
| E12 | Physical Therapist | Interviewed regarding pressure ulcer prevention and therapy |
| E14 | Certified Nursing Assistant (CNA) | Interviewed regarding pressure ulcer care and use of heel boots |
| E15 | Nurse Practitioner | Interviewed regarding pressure ulcer offloading |
| E16 | Certified Nursing Assistant (CNA) | Interviewed regarding use of palm guards and wedges |
| E17 | Rehab Director | Interviewed regarding use of palm protectors |
| E18 | Director of Food Services | Interviewed regarding food sanitation and sanitizer levels |
| E19 | Nursing Home Administrator (NHA) | Interviewed at exit conference regarding findings |
Inspection Report
Annual Inspection
Census: 63
Deficiencies: 11
Mar 16, 2022
Visit Reason
An unannounced Annual, Complaint and Emergency Preparedness survey was conducted at Delmar Nursing & Rehabilitation Center from March 9, 2022 through March 16, 2022 to assess compliance with federal and state regulations.
Findings
The survey identified multiple deficiencies related to accounting and records of personal funds, advance directives, safe environment, baseline care plans, care plan timing and revision, treatment and services to prevent pressure ulcers, pain management, nurse staffing information, drug regimen review, food procurement and safety, and abuse, neglect, and exploitation training. Corrective measures and monitoring plans were outlined for each deficiency.
Deficiencies (11)
| Description |
|---|
| Facility failed to provide quarterly statements of personal funds accounts for one resident. |
| Facility failed to ensure residents were offered the choice to formulate an advance directive. |
| Facility failed to provide a safe, clean, comfortable, and homelike environment in one resident room. |
| Facility failed to develop and implement baseline care plan within 48 hours of admission for one resident. |
| Facility failed to include required members in the interdisciplinary care team for one resident. |
| Facility failed to provide care and services to prevent pressure ulcers for one resident. |
| Facility failed to provide pain management in accordance with professional standards for one resident. |
| Facility failed to post accurate nurse staffing information daily. |
| Facility failed to conduct monthly drug regimen reviews and report irregularities to the attending physician for one resident. |
| Facility failed to ensure food was stored, prepared, and served in a sanitary manner. |
| Facility failed to provide required training on abuse, neglect, and exploitation to staff. |
Report Facts
Facility census: 63
Survey sample size: 26
Deficiency completion dates: Various corrective action completion dates listed, e.g., 4/23/22
Pain medication administrations lacking assessment: 16
Residents reviewed for personal funds: 3
Residents reviewed for advance directives: 3
Resident rooms reviewed for environment: 14
Residents reviewed for care plans: 26
Residents reviewed for pressure ulcers: 2
Residents reviewed for pain management: 2
Staff members reviewed for abuse training: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E7 | Social Worker | Interviewed regarding advance directives and care plan meetings |
| E10 | Business Office Manager | Interviewed regarding personal funds statements |
| E4 | Unit Manager | Interviewed regarding baseline care plan and medication review |
| E1 | Nursing Home Administrator | Participated in exit conference and findings review |
| E2 | Director of Nursing | Participated in exit conference and findings review |
| E3 | Assistant Director of Nursing | Participated in exit conference and findings review |
| E9 | Environmental Manager | Confirmed large hole in bathroom wall |
| E11 | Cook | Observed food safety violations in kitchen |
| E13 | Dietary Aide | Observed not wearing hairnet and confirmed sanitizing procedures |
| E12 | Dietary Manager | Confirmed dietary aide's hairnet violation and sanitizing process |
| E16 | Certified Nursing Assistant | Interviewed regarding resident care and pressure ulcer prevention |
| E15 | Licensed Practical Nurse | Reported unit manager responsible for CNA documentation |
| E19 | Certified Nursing Assistant | Confirmed elevation of resident's heels |
| E28 | Occupational Therapist | Staff member reviewed for abuse training |
| E29 | Physical Therapist Assistant | Staff member reviewed for abuse training |
| E31 | Educator | Confirmed absence of abuse training for staff |
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 0
Sep 10, 2021
Visit Reason
An unannounced COVID-19 Focus Infection Control Survey and Complaint Survey were conducted by the State of Delaware Division of Health Care Quality from September 8, 2021 through September 10, 2021.
Findings
The facility was found to be in compliance with 42 CFR §483.80 and implemented CDC recommended practices to prepare for COVID-19. There were no deficiencies identified during the survey.
Complaint Details
The survey included a complaint investigation component, but no deficiencies were identified.
Report Facts
Survey sample size: 6
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 1
May 7, 2021
Visit Reason
An unannounced Complaint Survey was conducted at the facility from May 5, 2021 through May 7, 2021 to investigate compliance with staffing requirements.
Findings
The facility was found out of compliance with staffing requirements, failing to maintain the minimum staffing level of 3.28 hours of direct care per resident per day for one day out of three weeks reviewed. No deficiencies were identified in the federal report.
Complaint Details
The complaint investigation found the facility failed to meet the minimum staffing requirements as substantiated by a desk review staffing audit conducted on May 7, 2021.
Deficiencies (1)
| Description |
|---|
| Facility failed to provide staffing at a level of at least 3.28 hours of direct care per resident per day on 5/3/2021. |
Report Facts
Facility census: 67
Survey sample size: 4
Minimum staffing requirement: 3.28
Staffing level on 5/3/2021: 3.18
Inspection Report
Routine
Census: 68
Deficiencies: 0
Oct 28, 2020
Visit Reason
A COVID-19 Focused Infection Control survey was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection on October 28, 2020.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19. No deficiencies were identified at the time of the survey.
Report Facts
Facility census: 68
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