Inspection Reports for
Excelcare at Lewes LLC
301 Ocean View Blvd., Lewes, DE, 19958
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
16.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
85% worse than Delaware average
Delaware average: 8.8 deficiencies/yearDeficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
69% occupied
Based on a February 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 14, 2025
Visit Reason
The inspection was conducted due to complaints of resident-to-resident abuse and failure to report and manage abuse incidents appropriately within the facility.
Complaint Details
The investigation was triggered by complaints of resident-to-resident abuse involving residents R1 and R2, including a physical altercation causing injury to R2. The facility also failed to report abuse allegations timely and failed to document clinical records accurately. Interviews with staff and residents confirmed the incidents and deficiencies.
Findings
The facility failed to protect residents from abuse, resulting in physical and psychosocial harm to a resident after a resident-to-resident altercation. The facility also failed to timely report suspected abuse to the State Agency and failed to maintain accurate clinical documentation for one resident.
Deficiencies (3)
F 0600: The facility failed to protect residents from abuse, resulting in physical harm to one resident after a resident-to-resident altercation and failed to implement adequate interventions to prevent harm.
F 0609: The facility failed to timely report suspected resident-to-resident abuse to the State Agency within two hours as required.
F 0842: The facility failed to ensure the clinical record contained accurate documentation for one resident, lacking progress notes and consult documentation after an incident.
Report Facts
Residents reviewed for abuse: 7
Residents affected: 2
Incident report submission delay: 1
1:1 supervision start date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Corporate NHA | Named during exit conference reviewing findings |
| E2 | DON | Named during exit conference reviewing findings |
| E3 | ADON | Named during exit conference and interviews confirming incident details |
| E6 | CNA | Interviewed confirming details of resident altercation and behaviors |
| E7 | CNA | Interviewed regarding resident behaviors and abuse allegations |
| E9 | CNA | Interviewed regarding resident behaviors and abuse incident |
| E11 | LPN | Interviewed regarding abuse allegation reporting process |
| E12 | LPN | Interviewed regarding resident behaviors and clinical documentation |
| E15 | LPN | Interviewed regarding notification of social worker and resident altercations |
| E4 | SW | Interviewed regarding IDT meetings and abuse allegation discussions |
| E16 | NP | Provided electronic communication regarding resident wellness check |
Inspection Report
Routine
Deficiencies: 12
Date: Feb 13, 2025
Visit Reason
Routine inspection of Excelcare at Lewes LLC nursing home to assess compliance with regulatory requirements related to resident care, abuse prevention, medication management, infection control, and safety.
Findings
The facility was found deficient in multiple areas including failure to maintain dignified care, prevent abuse and misappropriation, timely reporting and investigation of abuse allegations, wound care, accident prevention, catheter care, appropriate use of bed rails, medication administration errors, and infection control practices.
Deficiencies (12)
F 0550: The facility failed to ensure one resident received care that maintained a dignified dining experience, including timely bed linen changes before breakfast.
F 0600: The facility failed to protect one resident from verbal abuse by a staff member, resulting in potential psychosocial impairment.
F 0602: The facility failed to prevent misappropriation of medication by a licensed practical nurse who took a resident's Percocet, placing all residents at risk.
F 0609: The facility failed to timely report suspected abuse and failed to investigate an allegation of fear of a staff member by a resident, risking continued abuse.
F 0610: The facility failed to conduct a thorough investigation into an allegation of staff to resident abuse, risking other residents' safety.
F 0684: The facility failed to provide wound treatment as ordered and update the care plan accordingly for one resident, risking negative wound healing outcomes.
F 0686: The facility failed to provide all planned interventions for pressure ulcer care, including timely application of a low air loss mattress, risking further skin breakdown.
F 0689: The facility failed to prevent injuries during incontinence care for two residents by not following care plans requiring mechanical lift and two-person assistance.
F 0690: The facility failed to ensure appropriate physician orders and routine care for indwelling urinary catheters for two residents, risking inadequate catheter care.
F 0700: The facility failed to properly assess and document the need for side rails for one resident who was quadriplegic and unable to use the rails, risking unnecessary use and injury.
F 0760: The facility failed to prevent a significant medication error when a resident was administered Ativan and morphine without physician orders, risking over sedation and respiratory depression.
F 0880: The facility failed to implement effective infection control by not requiring gown use during PEG tube medication administration for a resident on contact isolation and delayed placing another resident on isolation after symptoms.
Report Facts
Residents reviewed: 46
Medication error date: 2024
Fall date: 2024
Medication error date: 7
Medication error date: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN4 | Registered Nurse | Named in medication error involving wrong administration of Ativan and morphine |
| CNA1 | Certified Nursing Assistant | Named in fall incident involving resident R171 |
| CNA2 | Certified Nursing Assistant | Witness to fall incident involving resident R171 |
| LPN1 | Licensed Practical Nurse | Responded to fall incident involving resident R171 |
| LPN2 | Licensed Practical Nurse | Observed not wearing gown during PEG tube medication administration for resident R320 |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including abuse, medication error, and infection control |
| ADON | Assistant Director of Nursing | Interviewed regarding multiple deficiencies including abuse, medication error, and infection control |
Inspection Report
Complaint Investigation
Census: 124
Deficiencies: 11
Date: 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.
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.
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.
Deficiencies (11)
Failure to ensure dignified dining experience for resident R79; bed linens were soiled and not changed timely.
Failure to ensure freedom from abuse and neglect; verbal abuse incident involving resident R21 and staff member.
Failure to ensure freedom from misappropriation/exploitation; Licensed Practical Nurse (LPN) 3 took Percocet from medication cart leading to misappropriation.
Failure to report and investigate alleged abuse timely and thoroughly for resident R77.
Failure to provide treatment and care in accordance with professional standards for resident R17's wound care.
Failure to prevent accidents and ensure adequate supervision and devices for residents R171 and R170 leading to injury and skin tear.
Failure to provide adequate bowel and bladder incontinence care for residents.
Failure to ensure appropriate catheter care and orders for residents R28 and R65.
Failure to ensure bedrails were used appropriately and safely for resident R65.
Failure to prevent significant medication errors; resident R176 received wrong medication dose.
Failure to implement effective infection prevention and control program; failure to identify COVID-19 in resident R80 timely.
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
Routine
Deficiencies: 12
Date: Feb 13, 2025
Visit Reason
Routine state inspection survey of Excelcare at Lewes LLC nursing home to assess compliance with regulatory requirements and resident care standards.
Findings
The facility was found deficient in multiple areas including failure to maintain dignified care, prevent abuse and misappropriation, provide appropriate wound and pressure ulcer care, prevent accidents, ensure proper catheter care, use bed rails appropriately, prevent medication errors, and implement effective infection control measures.
Deficiencies (12)
F 0550: The facility failed to ensure one resident received care that maintained a dignified dining experience, including timely bed linen changes before breakfast.
F 0600: The facility failed to protect one resident from verbal abuse by a staff member, resulting in potential psychosocial impairment.
F 0602: The facility failed to prevent misappropriation of medication when an LPN took a resident's Percocet, placing all residents at risk.
F 0609: The facility failed to timely report suspected abuse and failed to investigate an allegation of fear of a staff member by a resident.
F 0610: The facility failed to conduct a thorough investigation into an allegation of staff to resident abuse, risking other residents' safety.
F 0684: The facility failed to provide wound treatment as ordered and update the care plan accordingly for one resident, risking wound healing.
F 0686: The facility failed to provide all planned interventions for pressure ulcer care, including timely application of a low air loss mattress.
F 0689: The facility failed to prevent injuries during incontinence care for two residents by not following care plans requiring mechanical lift and two-person assistance.
F 0690: The facility failed to ensure appropriate physician orders and routine care for indwelling urinary catheters for two residents.
F 0700: The facility failed to properly assess and document the need for side rails on a resident's bed, resulting in potentially unnecessary use.
F 0760: The facility failed to prevent a significant medication error when a resident was given Ativan and Morphine without physician orders, risking over sedation.
F 0880: The facility failed to implement effective infection control by not using gowns during PEG tube medication administration and delayed isolation for a resident with COVID.
Report Facts
Residents in sample: 46
Medication error date: 2024
Fall date: 2024
Skin tear incident date: 2024
BIMS scores: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN4 | Registered Nurse | Named in medication error involving wrong administration of Ativan and Morphine |
| CNA1 | Certified Nursing Assistant | Named in fall incident involving resident R171 |
| LPN1 | Licensed Practical Nurse | Responded to fall incident involving resident R171 |
Inspection Report
Deficiencies: 4
Date: Mar 20, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, including reporting suspected abuse, ensuring physician orders at admission, treatment and care according to orders, and food preparation according to individual needs.
Findings
The facility was found deficient in timely reporting of suspected abuse, ensuring physician orders for immediate care at admission, providing appropriate treatment and care according to physician orders and professional standards, and preparing food in a form designed to meet individual resident needs. All deficiencies were assessed as causing minimal harm or potential for actual harm affecting few residents.
Deficiencies (4)
F 0609: The facility failed to timely report a bruise of unknown origin for one resident (R255) to the state agency within the required eight-hour timeframe.
F 0635: The facility failed to ensure physician orders for immediate care were present on admission for one resident (R309), including orders related to an indwelling urinary catheter and diabetic management.
F 0684: The facility failed to provide appropriate treatment and care according to physician orders and professional standards for one resident (R313) with bowel and bladder incontinence, including failure to implement bowel protocol after prolonged absence of bowel movements.
F 0805: The facility failed to prepare food in a form designed to meet the individual needs of one resident (R14), providing whole cauliflower florets instead of ground as ordered.
Report Facts
Residents reviewed for abuse: 3
Residents reviewed for admission orders: 2
Residents reviewed for bowel and bladder care: 1
Residents reviewed for food preparation: 1
Shifts without bowel movements for R313: 9
Total shifts without bowel movements on specific dates for R313: 20
Total shifts without bowel movements on specific dates for R313: 22
Total shifts without bowel movements on specific dates for R313: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Director of Nursing (DON) | Confirmed family was not notified and incident was not reported to State Agency regarding unreported bruise |
| E12 | Confirmed incident was not reported to State Agency regarding unreported bruise | |
| E1 | Nursing Home Administrator (NHA) | Participated in exit conference reviewing findings |
| E3 | Assistant Director of Nursing (ADON) | Participated in exit conference reviewing findings |
| E4 | Corporate Representative | Participated in exit conference reviewing findings |
| E19 | Certified Nursing Assistant (CNA) | Confirmed care was being completed for resident with indwelling urinary catheter |
| E15 | Utilization Manager (UM) | Confirmed admission process and responsibility for admission assessments and physician orders |
| E18 | Registered Nurse (RN) | Completed admission assessments and orders; admitted resident with indwelling urinary catheter but forgot to obtain batch orders |
| E16 | Registered Nurse (RN) | Confirmed bowel protocol and failure to implement it for resident with bowel incontinence |
| E22 | Food Service Director | Confirmed food was not prepared as ordered for resident on ground diet |
| E23 | Dietician | Confirmed resident was on ground diet and failed swallow study; confirmed food was not ground |
Inspection Report
Annual Inspection
Census: 110
Deficiencies: 9
Date: 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.
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.
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.
Deficiencies (9)
Facility failed to provide a clean and homelike environment, including dirt and food crumbs in resident rooms and peeling baseboards.
Facility failed to report a bruise of unknown origin on a resident within required timeframes.
Facility failed to ensure physician orders for immediate care were present for admitted residents.
Facility failed to ensure PASARR screenings and evaluations were completed and submitted timely for residents with qualifying diagnoses.
Facility failed to ensure quality of care related to bowel and bladder incontinence and constipation was provided according to professional standards and physician orders.
Facility failed to ensure a qualified person in charge was present in the kitchen during all hours of food service operation.
Facility failed to ensure resident call bells were functioning properly and residents had alternative means to call for assistance.
Facility failed to ensure physician reviewed resident's total program of care during visits and documented progress notes.
Facility failed to ensure food was prepared, stored, and served in a manner that prevents foodborne illness, including labeling and dating of food items.
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
Complaint Investigation
Deficiencies: 9
Date: Mar 20, 2024
Visit Reason
The inspection was conducted based on complaints and concerns regarding environmental cleanliness, abuse reporting, admission orders, PASARR screenings, treatment and care compliance, physician visits, food safety, and call bell functionality at the facility.
Complaint Details
The visit was complaint-related, triggered by concerns about environmental cleanliness, abuse reporting, admission orders, PASARR screenings, treatment and care compliance, physician visits, food safety, and call bell functionality. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in multiple areas including failure to maintain a clean and homelike environment in resident rooms, failure to timely report suspected abuse, lack of physician orders for immediate care on admission, failure to complete required PASARR screenings, inadequate treatment and care for bowel and bladder incontinence, incomplete physician review of resident care, insufficient qualified food service personnel, improper food storage and sanitation, and malfunctioning resident call bell systems.
Deficiencies (9)
F 0584: The facility failed to provide a clean and homelike environment in one room out of five reviewed, with dirt, food crumbs, black debris, and peeling baseboard present.
F 0609: The facility failed to timely report a bruise of unknown origin on a resident to the state agency within the required eight-hour timeframe.
F 0635: The facility failed to ensure physician orders for immediate care were present on admission for a resident with an indwelling urinary catheter and diabetes management.
F 0644: The facility failed to ensure referrals for PASARR screenings were completed for five residents after new psychiatric diagnoses or changes in condition.
F 0684: The facility failed to provide appropriate treatment and care for bowel and bladder incontinence, not implementing physician's bowel protocol orders for a resident.
F 0711: The facility failed to ensure the physician reviewed the total program of care, including medications and treatments, for a resident with an indwelling urinary catheter.
F 0802: The facility failed to ensure a qualified person in charge was present in the kitchen during all hours of food service operation.
F 0812: The facility failed to ensure food was stored, prepared, and served in a manner that prevents foodborne illness, including uncovered food, unlabeled and undated items, and insufficient sanitizer levels.
F 0919: The facility failed to ensure two call bells in a resident room were functioning properly, leaving residents without a means to call for help for four days.
Report Facts
Residents reviewed for environmental concerns: 5
Residents reviewed for abuse: 3
Residents reviewed for admission orders: 2
Residents reviewed for PASARR: 8
Residents reviewed for bowel and bladder care: 1
Residents reviewed for physician visits: 1
Days without bowel movements triggering protocol: 9
Days call bells were nonfunctional: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E24 | Floor Tech | Confirmed unclean room and cleaned it; notified maintenance about peeling baseboard. |
| E26 | Director of Maintenance | Confirmed peeling baseboard and acknowledged delayed repair. |
| E2 | Director of Nursing (DON) | Confirmed failure to report abuse and discussed findings at exit conference. |
| E15 | Utilization Manager (UM) | Confirmed admission process and responsibility for physician orders. |
| E18 | Registered Nurse (RN) | Admitted resident and completed admission assessments and orders; forgot to obtain batch orders. |
| E6 | Social Worker (SW) | Discussed PASARR screening requirements and failures. |
| E16 | Registered Nurse (RN) | Confirmed bowel protocol procedures and failure to implement for resident. |
| E5 | Nurse Practitioner (NP) | Confirmed lack of physician orders related to indwelling catheter use. |
| E27 | Dietary Aide | Disclosed only one staff member had valid Food Protection Manager certificate; observed food safety issues. |
| E7 | Registered Nurse (RN) | Confirmed call bell malfunction and lack of alternate call system. |
| E8 | Maintenance Director | Provided work order and explanation for delayed call bell repair. |
Inspection Report
Follow-Up
Census: 115
Deficiencies: 0
Date: 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
Date: 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.
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.
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.
Deficiencies (11)
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
Annual Inspection
Deficiencies: 9
Date: Feb 1, 2023
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements and evaluate the quality of care and services provided to residents.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, failure to notify residents of roommate changes, incomplete and non-individualized care plans, inadequate pressure ulcer care, lack of consistent activities programming, failure to provide appropriate respiratory care, and failure to accommodate resident food preferences.
Deficiencies (9)
F 0550: The facility failed to promote care that maintained or enhanced dignity and respect for two residents, including inappropriate references by staff.
F 0559: The facility failed to notify one resident in advance of a roommate change as required by policy.
F 0656: The facility failed to develop and implement a comprehensive person-centered care plan for one resident's chronic lower back pain, omitting non-pharmacological interventions.
F 0657: The facility failed to review, revise, and individualize the care plan of one resident to address overstimulation caused by excessively noisy music.
F 0658: The facility failed to meet professional standards in assessing and documenting a stage 2 pressure ulcer for one resident, including incorrect tissue identification.
F 0679: The facility lacked evidence of providing ongoing consistent activities including one-on-one visits as required by one resident's care plan.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers for two residents, including failure to turn a resident with a history of pressure ulcers and failure to provide prescribed orthotic padding.
F 0695: The facility failed to provide safe and appropriate respiratory care for one resident, including failure to ensure oxygen was used as ordered and lack of monitoring.
F 0806: The facility failed to accommodate one resident's food preferences by not providing condiments as indicated on meal tickets.
Report Facts
Residents reviewed for care plan: 29
Residents reviewed for pressure ulcers: 3
Residents reviewed for respiratory care: 1
Residents reviewed for food preferences: 2
Residents reviewed for dignity: 4
Residents affected by dignity deficiency: 2
Residents affected by roommate notification deficiency: 1
Residents affected by care plan deficiencies: 2
Residents affected by pressure ulcer care deficiency: 3
Residents affected by activities deficiency: 1
Residents affected by respiratory care deficiency: 1
Residents affected by food preference deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E7 | LPN | Named in findings related to dignity, pressure ulcer assessment, and respiratory care |
| E8 | CNA | Named in dignity deficiency for referring residents as feeders |
| E9 | CNA | Named in food preference deficiency for not including condiments on meal tray |
| E11 | Social Service Director (SSD) | Confirmed failure to notify resident of roommate change |
| E16 | Activities Director | Confirmed overstimulation and lack of individualized care plan for music preferences |
| E17 | Activities Aide | Reported lack of one-on-one activities for resident |
| E20 | Occupational Therapist (OT) | Provided education on orthotic padding and skin integrity |
| E21 | CNA | Confirmed resident did not refuse turning and repositioning |
| E22 | LPN | Documented wound care progress notes |
| E24 | RN | Confirmed education on orthotic padding placement |
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
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
Date: 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.
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.
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.
Deficiencies (4)
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
Date: 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
Date: 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.
Complaint Details
The visit was complaint-related as it included a Complaint Survey along with the COVID-19 Focused Infection Control Survey.
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.
Report Facts
Facility census: 133
Inspection Report
Annual Inspection
Census: 151
Deficiencies: 13
Date: 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.
Deficiencies (13)
Failure to ensure resident dignity and rights during dining for one resident out of 25 sampled.
Failure to develop and implement comprehensive care plans with measurable goals for residents.
Failure to ensure all required members of the Interdisciplinary Team participated in care planning for six residents.
Failure to provide activities that meet interests and needs of residents.
Failure to prevent pressure ulcers for one of five residents reviewed.
Failure to ensure bowel and bladder incontinence care and toileting plans for residents.
Failure to provide adequate pain management and assessment for one resident.
Failure to provide routine and emergency dental services to residents.
Failure to provide sufficient nursing staff to meet resident needs.
Failure to provide assistive devices and adaptive equipment for eating.
Failure to store food and supplements properly and discard expired items.
Failure to maintain an infection prevention and control program including proper isolation and contact precautions.
Failure to ensure psychotropic drugs are used appropriately and with proper documentation.
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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