Inspection Reports for Excelcare at Lewes LLC
301 Ocean View Blvd., Lewes, DE, 19958
Back to Facility ProfileInspection Report Summary
The most recent inspection on February 13, 2025 identified multiple deficiencies related to resident care, abuse prevention, medication management, and infection control. Earlier inspections showed a pattern of similar issues including care planning, resident dignity, food safety, and timely reporting of abuse, with substantiated complaints in several cases. Inspectors cited failures in ensuring a dignified dining experience, preventing abuse and neglect, proper wound and catheter care, medication errors, and infection prevention. Complaint investigations were substantiated multiple times, including incidents of verbal abuse, medication misappropriation, and failure to report injuries and abuse promptly. The facility’s inspection history indicates ongoing challenges with compliance, with deficiencies persisting over time rather than clear improvement.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
8.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
7% better than Delaware average
Delaware average: 8.8 deficiencies/year
Deficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
124 residents
Based on a February 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 124
Deficiencies: 11
Feb 13, 2025
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 from 02/10/25 through 02/13/25. The facility was found not to be in substantial compliance with 42 CFR 483 subpart B.
Findings
The facility failed to ensure dignified dining experience, freedom from abuse and neglect, freedom from misappropriation/exploitation, quality of care, accident prevention, and infection control among other requirements. Multiple residents were affected by these deficiencies, including issues with bed linens, medication errors, abuse investigations, wound care, and catheter care.
Complaint Details
The complaint investigation was substantiated with multiple deficiencies found related to resident rights, abuse, neglect, misappropriation, quality of care, and safety issues affecting several residents.
Severity Breakdown
SS=D: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to ensure dignified dining experience for resident R79; bed linens were soiled and not changed timely. | SS=D |
| Failure to ensure freedom from abuse and neglect; verbal abuse incident involving resident R21 and staff member. | SS=D |
| Failure to ensure freedom from misappropriation/exploitation; Licensed Practical Nurse (LPN) 3 took Percocet from medication cart leading to misappropriation. | SS=D |
| Failure to report and investigate alleged abuse timely and thoroughly for resident R77. | SS=D |
| Failure to provide treatment and care in accordance with professional standards for resident R17's wound care. | SS=D |
| Failure to prevent accidents and ensure adequate supervision and devices for residents R171 and R170 leading to injury and skin tear. | SS=D |
| Failure to provide adequate bowel and bladder incontinence care for residents. | SS=D |
| Failure to ensure appropriate catheter care and orders for residents R28 and R65. | SS=D |
| Failure to ensure bedrails were used appropriately and safely for resident R65. | SS=D |
| Failure to prevent significant medication errors; resident R176 received wrong medication dose. | SS=D |
| Failure to implement effective infection prevention and control program; failure to identify COVID-19 in resident R80 timely. | SS=D |
Report Facts
Census: 124
Sample size: 46
Supplemental sample: 13
Deficiencies with severity SS=D: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse RN3 | Named in finding related to failure to change bed linens timely for resident R79 | |
| Licensed Practical Nurse LPN3 | Named in misappropriation of medication involving Percocet | |
| Director of Nursing DON | Director of Nursing | Involved in multiple interviews and findings related to abuse investigations and medication errors |
| Assistant Director of Nurses ADON | Assistant Director of Nurses | Involved in interviews and findings related to abuse investigations and resident care |
| Certified Nursing Assistant CNA1 | Named in fall incident investigation for resident R171 | |
| Certified Nursing Assistant CNA2 | Named in fall incident investigation for resident R171 | |
| Registered Nurse RN4 | Named in medication error involving resident R176 | |
| Licensed Practical Nurse LPN1 | Named in fall incident investigation for resident R171 | |
| Licensed Practical Nurse LPN2 | Named in infection control and medication administration findings |
Inspection Report
Annual Inspection
Census: 110
Deficiencies: 9
Mar 20, 2024
Visit Reason
An unannounced annual, complaint, and emergency preparedness survey was conducted at the facility from March 11, 2024 through March 20, 2024 to assess compliance with federal and state regulations.
Findings
The survey identified multiple deficiencies related to safe environment, reporting of alleged violations, admission physician orders, PASARR screening and assessments, quality of care, food safety, resident call system, and staff qualifications. The facility failed to ensure a clean and homelike environment, timely reporting of abuse allegations, accurate clinical documentation, and proper food service management.
Complaint Details
The survey included complaint investigation components. It was substantiated that the facility failed to report a bruise of unknown origin on resident R255 within required timeframes and failed to notify the family. The facility also failed to identify and report the bruise as a reportable event to the State Agency.
Severity Breakdown
Level 2: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Facility failed to provide a clean and homelike environment, including dirt and food crumbs in resident rooms and peeling baseboards. | Level 2 |
| Facility failed to report a bruise of unknown origin on a resident within required timeframes. | Level 2 |
| Facility failed to ensure physician orders for immediate care were present for admitted residents. | Level 2 |
| Facility failed to ensure PASARR screenings and evaluations were completed and submitted timely for residents with qualifying diagnoses. | Level 2 |
| Facility failed to ensure quality of care related to bowel and bladder incontinence and constipation was provided according to professional standards and physician orders. | Level 2 |
| Facility failed to ensure a qualified person in charge was present in the kitchen during all hours of food service operation. | Level 2 |
| Facility failed to ensure resident call bells were functioning properly and residents had alternative means to call for assistance. | Level 2 |
| Facility failed to ensure physician reviewed resident's total program of care during visits and documented progress notes. | Level 2 |
| Facility failed to ensure food was prepared, stored, and served in a manner that prevents foodborne illness, including labeling and dating of food items. | Level 2 |
Report Facts
Facility census: 110
Survey sample size: 37
Deficiency completion dates: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E24 | Floor Tech | Interviewed regarding room cleaning and maintenance issues |
| E26 | Director of Maintenance | Interviewed regarding maintenance issues and baseboard repairs |
| E2 | Director of Nursing (DON) | Interviewed regarding incident reporting and family notification |
| E1 | Nursing Home Administrator (NHA) | Participated in exit conference and findings review |
| E3 | Assistant Director of Nursing (ADON) | Participated in exit conference and findings review |
| E4 | Corporate Representative | Participated in exit conference and findings review |
| E25 | Director of Environmental Services | Interviewed regarding cleaning schedules and resident preferences |
| E18 | Registered Nurse (RN) | Interviewed regarding admission assessments and physician orders |
| E15 | Unit Manager (UM) | Interviewed regarding admission process and PASARR requests |
| E19 | Certified Nurse Aide (CNA) | Interviewed regarding resident care |
| E5 | Nurse Practitioner (NP) | Interviewed regarding physician orders and clinical documentation |
| E16 | Registered Nurse (RN) | Interviewed regarding bowel protocol and monitoring |
| E7 | Registered Nurse (RN) | Interviewed regarding resident call bell system |
| E8 | Maintenance Director | Interviewed regarding repair of call bells |
| E27 | Dietary Aide | Interviewed regarding food service certification |
| E22 | Food Service Director | Interviewed regarding food preparation and resident diet |
| E23 | Dietician | Interviewed regarding resident diet and swallow study |
Inspection Report
Follow-Up
Census: 115
Deficiencies: 0
Apr 4, 2023
Visit Reason
An unannounced Follow-Up Survey for the Annual and Complaint Survey ending February 1, 2023, was conducted at this facility by the State of Delaware Division of Health Care Quality Office of Long Term Care Residents Protection from April 3, 2023 through April 4, 2023.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care as of March 20, 2023.
Report Facts
Survey sample size: 11
Inspection Report
Annual Inspection
Census: 119
Deficiencies: 11
Feb 1, 2023
Visit Reason
An unannounced Annual and Complaint Survey was conducted at Harbor Healthcare & Rehabilitation Center from January 24, 2023 through February 1, 2023. The survey included observations, interviews, and review of clinical records and other facility documents.
Findings
The facility was found to have multiple deficiencies related to resident rights, care planning, pressure ulcer prevention, pain management, respiratory care, and resident records. The facility failed to provide care consistent with professional standards in several areas, including dignity, individualized care plans, and proper documentation.
Complaint Details
The survey was both an annual and complaint investigation. Specific complaint details are not separately stated but the survey included complaint-related findings.
Deficiencies (11)
| Description |
|---|
| Failure to promote resident dignity and respect for two of four sampled residents. |
| Failure to notify one resident of room/roommate change. |
| Failure to develop and implement a comprehensive person-centered care plan for one of twenty-nine residents. |
| Failure to develop individualized care plan for chronic lower back pain including non-pharmacological interventions. |
| Failure to review, revise, and individualize care plan for one resident with noisy music causing overstimulation. |
| Failure to meet professional standards for pressure ulcer care for one of three residents reviewed. |
| Failure to provide ongoing consistent activities program for one resident. |
| Failure to provide respiratory care consistent with physician orders and comprehensive care plan for one resident. |
| Failure to provide pain management according to professional standards for one of three residents reviewed for pain. |
| Failure to provide food preferences and choices for one resident. |
| Failure to maintain accurate and complete resident records including medication administration and controlled substance documentation. |
Report Facts
Residents present: 119
Residents sampled: 29
Deficiency completion dates: 3
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 1
Oct 10, 2022
Visit Reason
An unannounced Complaint Survey was conducted at Harbor Healthcare & Rehabilitation Center from October 3, 2022 through October 10, 2022 to investigate complaints and assess compliance with regulatory requirements.
Findings
The facility failed to consistently monitor food temperatures prior to food service, with 75 out of 549 meals (13.7%) lacking evidence of temperature monitoring. The Food Service Director confirmed temperatures were not taken at every meal.
Complaint Details
The survey was complaint-driven and unannounced. The findings were based on observations, interviews, and review of clinical and facility documentation. The complaint was substantiated by the failure to monitor food temperatures as required.
Deficiencies (1)
| Description |
|---|
| Failure to consistently monitor food temperatures prior to food service. |
Report Facts
Facility census: 111
Survey sample size: 21
Meals lacking temperature monitoring: 75
Percentage of meals lacking monitoring: 13.7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E3 | Food Service Director | Confirmed temperatures were not taken at every meal during interview |
| E1 | Nursing Home Administrator | Findings reviewed with during exit conference |
| E2 | Director of Nursing | Findings reviewed with during exit conference |
Inspection Report
Complaint Investigation
Census: 123
Deficiencies: 4
Feb 11, 2021
Visit Reason
An unannounced COVID-19 Focused Infection Control Survey and Complaint Survey was conducted by the State of Delaware Division of Health Care Quality from February 4, 2021 through February 11, 2021 to assess compliance with infection control regulations and investigate a complaint regarding abuse reporting and other regulatory requirements.
Findings
The facility was found not to be in compliance with 42 CFR §483.80 infection control regulations and failed to implement CDC recommended COVID-19 practices. Deficiencies included failure to report abuse incidents properly, incomplete tuberculosis testing documentation for staff, inadequate care plan participation, and failure to conduct proper COVID-19 symptom screening and PPE doffing procedures.
Complaint Details
The complaint investigation found that the facility failed to report an abuse incident properly and that staff were not aware of all components required for reporting alleged abuse, neglect, mistreatment, or financial exploitation. The facility amended the abuse report during the 5-day follow-up. The complaint was substantiated.
Deficiencies (4)
| Description |
|---|
| Failure to report required content about an abuse incident to the State Agency. |
| Failure to follow State tuberculosis testing requirements for staff with positive skin tests. |
| Failure to ensure all required members of the Interdisciplinary Team participated in or provided input to the formation of a resident's care plan. |
| Failure to establish and maintain an infection prevention and control program including COVID-19 symptom screening and PPE doffing procedures. |
Report Facts
Facility census: 123
Survey sample size: 19
Staff sampled for TB testing: 6
Residents sampled for abuse: 4
Residents sampled for care plans: 4
Residents sampled for COVID-19 symptom screening: 4
Nursing units with PPE doffing issues: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Director of Nursing (DON) | Named in abuse reporting deficiency and communication regarding incident reports. |
| E1 | Nursing Home Administrator (NHA) | Participated in exit teleconference and communication regarding findings. |
| E3 | Assistant Director of Nursing (ADON) | Participated in exit teleconference and review of findings. |
| E4 | Administrator in Training (AIT) | Documented care conference attendance and participated in exit teleconference. |
| E5 | Regional Vice President (Regional VP) | Participated in exit teleconference and review of findings. |
| E17 | Staff Educator | Notified of PPE doffing and isolation gown deficiencies and involved in staff education. |
Inspection Report
Routine
Census: 127
Deficiencies: 0
Dec 22, 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 December 22, 2020.
Findings
The facility was found to be in compliance with 42 CFR §483.80 and had implemented the CMS and CDC recommended practices to prepare for COVID-19. No deficiencies were identified at the time of the survey.
Report Facts
Facility census: 127
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan P. Sheehan | NHA | Signed as Laboratory Director or Provider/Supplier Representative |
Inspection Report
Complaint Investigation
Census: 133
Deficiencies: 0
Nov 6, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and Complaint Survey was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection on November 6, 2020.
Findings
The facility was found to be in compliance with 42 CFR §483.80 and has implemented the CMS and CDC recommended practices to prepare for COVID-19. No deficiencies were identified at the time of the survey.
Complaint Details
The visit was complaint-related as it included a Complaint Survey along with the COVID-19 Focused Infection Control Survey.
Report Facts
Facility census: 133
Inspection Report
Annual Inspection
Census: 151
Deficiencies: 13
Feb 18, 2020
Visit Reason
An unannounced annual and complaint survey was conducted at the facility from February 10, 2020 through February 18, 2020, including an Emergency Preparedness Survey by the State of Delaware's Division of Health Care Quality.
Findings
The facility was found to have multiple deficiencies including failure to ensure resident rights, comprehensive care planning, sufficient nursing staff, infection prevention and control, and proper management of pressure ulcers, bowel and bladder incontinence, pain management, dental services, and psychotropic drug use. The facility also failed to maintain proper labeling and storage of enteral feeding and supplements, and failed to provide adequate activities and care conferences.
Severity Breakdown
SS=D: 11
SS=E: 2
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to ensure resident dignity and rights during dining for one resident out of 25 sampled. | SS=D |
| Failure to develop and implement comprehensive care plans with measurable goals for residents. | SS=D |
| Failure to ensure all required members of the Interdisciplinary Team participated in care planning for six residents. | SS=E |
| Failure to provide activities that meet interests and needs of residents. | SS=D |
| Failure to prevent pressure ulcers for one of five residents reviewed. | SS=D |
| Failure to ensure bowel and bladder incontinence care and toileting plans for residents. | SS=D |
| Failure to provide adequate pain management and assessment for one resident. | SS=D |
| Failure to provide routine and emergency dental services to residents. | SS=D |
| Failure to provide sufficient nursing staff to meet resident needs. | SS=E |
| Failure to provide assistive devices and adaptive equipment for eating. | SS=D |
| Failure to store food and supplements properly and discard expired items. | SS=D |
| Failure to maintain an infection prevention and control program including proper isolation and contact precautions. | SS=D |
| Failure to ensure psychotropic drugs are used appropriately and with proper documentation. | SS=D |
Report Facts
Facility census: 151
Sample size: 32
Number of residents sampled for dignity during dining: 25
Number of residents sampled for comprehensive care plan review: 25
Number of residents sampled for care conference review: 25
Number of residents reviewed for pressure ulcers: 5
Number of residents reviewed for bowel and bladder incontinence: 3
Number of residents reviewed for pain management: 1
Number of residents reviewed for dental services: 1
Number of residents reviewed for psychotropic drug use: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator (NHA) | Named in review and exit conference of findings |
| E2 | Director of Nursing (DON) | Named in review and exit conference of findings |
| E3 | Assistant Director of Nursing (ADON) | Interviewed regarding care plan updates |
| E5 | Registered Nurse (RN) | Interviewed regarding care conferences and resident care |
| E7 | Licensed Practical Nurse (LPN) | Interviewed regarding resident care and care conferences |
| E9 | Social Work Assistant (SWA) | Interviewed regarding care conferences |
| E11 | Speech Language Pathologist (SLP) | Observed during infection control and contact precautions |
| E13 | Licensed Practical Nurse (LPN) | Interviewed regarding pain assessment and resident care |
| E14 | Certified Nursing Assistant (CNA) | Interviewed regarding resident pain and care |
| E17 | Medical Director | Named in review and exit conference of findings |
| E18 | Corporate Nurse | Named in review and exit conference of findings |
| E19 | Certified Nursing Assistant (CNA) | Interviewed regarding resident toileting |
| E27 | Regional Vice President (VP) | Named in review and exit conference of findings |
| E34 | Certified Nursing Assistant (CNA) | Interviewed regarding resident feeding assistance |
| E35 | Registered Dietitian (RD) | Interviewed regarding resident feeding and weight loss |
| E36 | Rehab Director | Interviewed regarding occupational therapy and resident feeding |
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