Deficiencies (last 3 years)
Deficiencies (over 3 years)
14.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
67% worse than Delaware average
Delaware average: 8.8 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 2
Oct 22, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory standards related to pressure ulcer care, hydration, and overall resident health at Delaware Bay Rehabilitation and Healthcare Center.
Findings
The facility was found deficient in providing appropriate pressure ulcer care and preventing new ulcers, resulting in actual harm to residents. Additionally, the facility failed to ensure adequate hydration for a resident, leading to hospitalization with acute kidney injury and metabolic acidosis.
Severity Breakdown
Level of Harm - Actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, resulting in an avoidable unstageable pressure ulcer causing harm. | Level of Harm - Actual harm |
| Failure to provide enough food/fluids to maintain a resident's health, resulting in harm due to dehydration and related complications. | Level of Harm - Actual harm |
Report Facts
Residents reviewed for pressure ulcer: 3
Residents affected by pressure ulcer deficiency: 1
Residents reviewed for hydration: 1
Residents affected by hydration deficiency: 1
Pressure ulcer measurements: 28
Pressure ulcer measurements: 22
Braden scale score: 18
Fluid intake (mL): 1724
Fluid intake (mL): 2155
Creatinine level (mg/dL): 9.1
BUN level (mg/dL): 155
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Director of Nursing (DON) | Reviewed findings during exit conference |
| E3 | Wound Care Nurse (WCN) | Assessed wounds and confirmed treatment details for resident R1 |
| E4 | Licensed Practical Nurse (LPN) | Provided wound care and confirmed treatment expectations for resident R1 |
| E5 | Licensed Practical Nurse (LPN) | Confirmed admission assessment and wound care responsibilities |
| E6 | Certified Nursing Assistant (CNA) | Confirmed resident dependency and wound condition |
| E7 | Certified Nursing Assistant (CNA) | Confirmed resident dependency and wound condition |
| E8 | Wound Care Physician (WC MD) | Ordered wound treatments and assessed resident R1 |
| E9 | Licensed Practical Nurse Unit Manager (LPN UM) | Interviewed regarding reporting of decreased intake |
| E10 | Dietician | Reviewed nutritional status and intake of resident R1 |
| E11 | MDS Coordinator | Signed off admission MDS documenting pressure ulcer |
Inspection Report
Routine
Census: 28
Deficiencies: 2
Jul 31, 2025
Visit Reason
The inspection was conducted to assess the facility's infection prevention and control practices, specifically related to medication administration and PICC line care.
Findings
The facility failed to ensure proper infection prevention practices for two residents, including improper hand hygiene during medication administration and failure to wear gowns when accessing a PICC line, posing minimal harm or potential for actual harm.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to perform hand hygiene between medication administrations and touching medications with bare hands. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to wear gowns and follow transmission-based precautions when administering antibiotics and flushing PICC line tubing. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 28
Residents affected: 2
Medication administration observation times: 2
PICC line care observation times: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN | E18 observed failing to perform hand hygiene and touching medications with bare hands | |
| Agency LPN | E19 observed not wearing gown while accessing PICC line and administering saline flush | |
| NHA | E1 participated in exit conference reviewing findings | |
| DON | E2 participated in exit conference reviewing findings | |
| ADON | E3 participated in exit conference reviewing findings |
Inspection Report
Routine
Deficiencies: 7
Jul 31, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, infection control, and facility safety at Delaware Bay Rehabilitation and Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to complete timely PASRR referrals for residents with new mental health diagnoses, incomplete care planning for hospice residents, inadequate pressure ulcer care, unsafe respiratory care practices, significant medication errors resulting in immediate jeopardy, failure to follow infection prevention protocols, and failure to maintain essential kitchen equipment at proper sanitizing levels.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure new PASRR referrals were completed upon new mental health diagnoses and psychotropic medication starts for residents R31 and R10. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop a complete care plan addressing hospice needs for resident R3. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to turn and reposition resident R74 to promote healing of a pressure ulcer. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure oxygen tubing and humidifier bottle were changed weekly for R18 and improper storage of BiPAP equipment for R98. | Level of Harm - Minimal harm or potential for actual harm |
| Significant medication errors for residents R129 and R123 resulting in immediate jeopardy, including administration of another resident's medication and insulin given outside of parameters. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to follow infection prevention practices including hand hygiene during medication administration and lack of gown use when accessing PICC line for resident R97. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain appropriate sanitizing chemical concentration in kitchen sanitizer buckets and three compartment sink. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for PASRR: 2
Residents reviewed for hospice care planning: 28
Residents reviewed for pressure ulcer care: 1
Residents reviewed for respiratory care: 4
Residents reviewed for medication errors: 2
Residents reviewed for infection prevention: 28
Sanitizer chemical concentration: 400
Sanitizer chemical concentration: 200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E11 | Social Worker (SW) | Confirmed PASRR referral was not completed for R31 |
| E2 | Director of Nursing (DON) | Provided copy of new PASRR assessment for R31; confirmed findings on hospice care plan and medication error education |
| E20 | Social Worker (SW) | Entered PASRR resubmission for R10 |
| E8 | Certified Nursing Assistant (CNA) | Interviewed regarding repositioning of resident R74 |
| E4 | Licensed Practical Nurse (LPN) | Confirmed repositioning failure for R74 and replaced undated oxygen tubing for R18 |
| E13 | RN Educator / Staff Educator | Observed BiPAP storage and provided education on medication errors |
| E5 | Registered Nurse (RN) | Confirmed medication error for R129 and reporting |
| E17 | Licensed Practical Nurse (LPN) | Administered wrong medication to R129 and reported error |
| E12 | Registered Nurse (RN) - Agency | Administered insulin to R123 outside parameters |
| E18 | Licensed Practical Nurse (LPN) | Observed failing hand hygiene and improper medication handling |
| E19 | Agency Licensed Practical Nurse (LPN) | Did not wear gown when accessing PICC line for R97 |
| E16 | Dietary Supervisor | Tested sanitizer chemical concentration in kitchen |
Inspection Report
Routine
Deficiencies: 6
Aug 9, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident dignity, abuse reporting, nursing assessments, behavioral health services, medication administration, and nutritional services.
Findings
The facility was found deficient in multiple areas including failure to promote resident dignity, delayed reporting of injury of unknown source, improper completion of admission assessments by LPNs instead of RNs, failure to provide necessary behavioral health services, significant medication errors involving insulin administration leading to immediate jeopardy, and failure to ensure dietician-approved menus were followed and residents received the correct meals.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to promote resident dignity for one resident related to an agency nurse posting a video on social media. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely report suspected abuse or injury of unknown source for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Licensed Practical Nurses completed admission assessments and progress notes instead of Registered Nurses for eight residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide necessary behavioral health services to one resident with mood and behavioral issues. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure four residents were free from significant medication errors involving insulin administration and blood sugar monitoring, resulting in immediate jeopardy. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to ensure dietician-approved menus were followed and residents received the correct food items for two residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for dignity: 28
Residents reviewed for abuse: 14
Residents reviewed for assessments: 23
Residents reviewed for behavioral health: 2
Residents reviewed for medication errors: 7
Residents reviewed for nutrition: 10
Likes on social media video: 45
Comments on social media video: 4
Bruise size on resident R90: 8.5
Bruise size on resident R90: 6.4
Medication administration errors: 4
Immediate Jeopardy abatement date: Aug 6, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E10 | Registered Nurse (RN), former employee | Named in dignity violation related to social media video |
| E2 | Assistant Director of Nursing (ADON) | Confirmed cell phone policy violation and delayed injury reporting |
| E17 | Licensed Practical Nurse (LPN) | Documented bruise on resident R90 |
| E18 | Registered Nurse (RN), former employee | Documented bruise progression and involved in medication errors |
| E23 | Director of Nursing (DON) | Interviewed regarding admission assessments and medication error investigation |
| E1 | Nursing Home Administrator (NHA) | Participated in exit conferences and IJ review |
| E3 | Quality Assurance Registered Nurse (QA RN) | Participated in exit conferences and IJ review |
| E4 | MDS Licensed Practical Nurse (MDS LPN) | Participated in exit conferences |
| E7 | Dietician | Interviewed regarding menu substitutions and nutritional deficiencies |
| E6 | Dietary Director | Interviewed regarding menu substitutions |
| E19 | Certified Nursing Assistant (CNA) | Witnessed inappropriate touching behavior of resident |
| E22 | Licensed Practical Nurse (LPN) | Confirmed initiation of behavioral monitoring |
| E12 | Medical Doctor (MD) | Confirmed expectations for reporting behavioral issues |
| E11 | Certified Nursing Assistant (CNA) | Confirmed missing food items on resident trays |
Inspection Report
Routine
Deficiencies: 13
Aug 9, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including PASARR screening, admission assessments, discharge summaries, ADL care, continence care, nutrition, medication management, infection prevention and control, and kitchen safety.
Findings
The facility was found deficient in multiple areas including failure to complete PASARR Level II referrals for residents with serious mental illness, Licensed Practical Nurses performing admission assessments contrary to state regulations, lack of discharge summaries at time of discharge, inadequate ADL care for dependent residents, failure to provide toileting programs for incontinent residents, failure to recognize and address significant weight loss, failure to monitor physician visits for nutritional status, unnecessary psychotropic medication use, failure to follow dietician approved menus, unsafe food handling and storage practices, inadequate infection prevention and control program including failure to implement enhanced barrier precautions for MDRO colonized residents, and failure to maintain essential kitchen equipment in safe operating condition.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 13
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to ensure referral for PASARR Level II screening for residents with serious mental illness. | Level of Harm - Minimal harm or potential for actual harm |
| Licensed Practical Nurses completed admission assessments and progress notes contrary to Delaware State Board of Nursing regulations. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide a discharge summary including reaccounting of stay and review of pre-discharge medications at time of discharge. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide necessary grooming services to dependent residents, evidenced by long nails and debris. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide services to restore bladder continence and establish toileting programs for incontinent residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to recognize and address significant weight loss in a resident, including delayed nutritional interventions. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure physician visits included evaluation of resident's condition and care to address significant weight loss. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure residents were free from unnecessary psychotropic medications including lack of diagnosis documentation, failure to limit PRN use, and inadequate monitoring. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure dietician approved menus were followed and residents received selected food items. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure food was stored, prepared, and served in a manner that prevents food borne illness, including thawing frozen food improperly, missing date labels, rusted shelves, insufficient sanitizer levels, and undated nutritional shakes. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to establish and maintain an infection prevention and control program including failure to initiate enhanced barrier precautions for residents with MDRO colonization, inadequate infection surveillance documentation, and lack of staff training on safe laundry handling. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement an antibiotic stewardship program that monitors antibiotic use for correct indication and duration. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to keep essential kitchen equipment in safe operating condition, evidenced by significant ice build-up on damaged protective grate covering freezer fans. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Weight loss: 14.6
Weight loss: 17
Bed baths received: 32
Bed baths received: 29
Incontinence episodes: 9
Incontinence episodes: 2
Incontinence episodes: 7
Incontinence episodes: 10
Incontinence episodes: 27
Incontinence episodes: 24
Incontinence episodes: 33
Incontinence episodes: 39
Incontinence episodes: 24
Incontinence episodes: 12
Incontinence episodes: 20
Incontinence episodes: 5
Incontinence episodes: 4
Incontinence episodes: 8
Duration of contact precautions not implemented: 94
Duration of contact precautions not implemented: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E8 | Social Worker (SW) | Interviewed regarding PASARR screening and confirmed lack of Level II submission for residents R37 and R47. |
| E1 | Nursing Home Administrator (NHA) | Participated in exit conferences reviewing findings. |
| E2 | Assistant Director of Nursing (ADON) | Participated in exit conferences reviewing findings and provided email correspondence on lab report status. |
| E3 | Quality Assurance Registered Nurse (QA RN) | Participated in exit conferences reviewing findings. |
| E4 | MDS Licensed Practical Nurse (MDS LPN) | Participated in exit conferences reviewing findings and provided information on continence monitoring. |
| E11 | Certified Nursing Assistant (CNA) | Confirmed nail care expectations and missing meal items. |
| E12 | Medical Doctor (MD) | Ordered medications, provided physician notes, and participated in interviews regarding weight loss, medication monitoring, and infection control. |
| E13 | Physician Assistant (PA) | Ordered medications, documented progress notes, and participated in interviews regarding infection control and medication monitoring. |
| E7 | Dietician | Documented nutritional assessments and participated in interviews regarding weight loss and menu substitutions. |
| E6 | Dietary Director | Interviewed regarding menu substitutions and sanitizer testing. |
| E5 | Laundry Aide | Observed handling soiled laundry without gloves and reported lack of training. |
| E31 | Infection Preventionist (IP) | Provided email correspondence and interviews regarding infection prevention program and MDRO colonization. |
| E25 | Unit Manager (UM) | Reported resident R102's excessive daytime sleepiness to provider. |
| E19 | Certified Nursing Assistant (CNA) | Confirmed resident R100 was not on toileting program. |
| E26 | Certified Nursing Assistant (CNA) | Confirmed resident R102 was sleeping more and missing meals. |
| E28 | Certified Nursing Assistant (CNA) | Confirmed resident R61 was dependent on staff for toileting. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Jun 6, 2023
Visit Reason
The inspection was conducted based on complaints and allegations regarding resident dignity, abuse reporting, notification of transfers, and treatment adherence at Delaware Bay Rehabilitation and Healthcare Center.
Findings
The facility failed to promote resident dignity for two residents by not covering urinary catheter bags and verbal inappropriate behavior by staff. Staff failed to immediately report an allegation of abuse to the Administrator and State Agency. The facility did not provide written notice to residents or representatives before transfers. The facility also failed to consistently apply prescribed lymphedema pumps for one resident.
Complaint Details
The complaint investigation included allegations of verbal abuse by a day-shift nurse, failure to report abuse allegations timely, failure to provide written notice of transfers, and failure to apply prescribed treatments consistently. The complaint was substantiated with findings confirmed by interviews and record reviews.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to promote resident dignity by not covering urinary catheter bags and verbal inappropriate behavior by staff. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report suspected abuse to the Administrator and State Agency. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide timely notification to residents or representatives before transfer or discharge. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate treatment and care by not consistently applying lymphedema pumps as prescribed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Missed treatment opportunities: 17
Residents reviewed for dignity: 3
Residents affected: 2
Residents reviewed for abuse: 2
Residents affected: 1
Residents reviewed for hospitalization notification: 2
Residents affected: 2
Residents reviewed for ADL care: 3
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E18 | LPN | Named in verbal inappropriate behavior finding related to resident R455. |
| E1 | NHA | Confirmed findings related to dignity, abuse reporting, transfer notification, and treatment application during interviews and exit conferences. |
| E17 | LPN | Confirmed observation of urinary catheter bag without privacy covering for resident R51. |
| E19 | CNA | Received abuse training, wrote statement alleging verbal abuse, but failed to report allegations timely. |
| E2 | DON | Participated in exit conferences reviewing findings. |
| E3 | ADON | Confirmed missed opportunities for application of lymphedema pumps for resident R355. |
| E16 | Clinical Liaison | Confirmed failure to provide written notice of transfer for resident R81. |
Inspection Report
Annual Inspection
Deficiencies: 10
Jun 6, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for Delaware Bay Rehabilitation and Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to promote resident dignity, failure to provide timely transfer notifications, incomplete care plans, inadequate ADL care, inconsistent application of prescribed treatments, respiratory care deficiencies, lack of staff performance evaluations and training, unsafe food storage and handling, and incomplete attendance at required Quality Assessment and Assurance meetings.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to promote resident dignity for two residents related to verbal interactions and urinary catheter privacy. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide timely written notification to residents or representatives before transfer or discharge for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to update care plan to include refusal of care for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide nail care for dependent resident due to refusals and lack of documentation. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to consistently apply prescribed lymphedema pumps for one resident with missed treatment opportunities. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure oxygen humidifier bottle and tubing were changed weekly and tubing/nasal cannula stored properly for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Lack of evidence of annual performance evaluation for one CNA. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure safe sanitary storage of food, protect food quality, and maintain consistent food temperature logs. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure attendance of required members, specifically Medical Director, at two of three quarterly Quality Assessment and Assurance meetings. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure required trainings on abuse, neglect, exploitation, and dementia management were completed for three staff members. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Missed treatment opportunities: 17
Meals without temperature recorded: 546
Quarterly QA/QAPI meetings without Medical Director attendance: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | NHA | Confirmed multiple findings during interviews and exit conferences. |
| E2 | DON | Confirmed multiple findings during interviews and exit conferences. |
| E3 | ADON | Confirmed missed treatment opportunities for lymphedema pumps. |
| E4 | Dining Services Director | Confirmed food storage and sanitation deficiencies. |
| E8 | LPN | Named in dignity deficiency and lack of dementia training. |
| E10 | LPN | Named in lack of abuse, neglect, exploitation, and dementia training. |
| E14 | RN | Named in lack of dementia training. |
| E15 | CNA | Named in lack of annual performance evaluation. |
| E17 | LPN | Confirmed urinary catheter bag privacy deficiency. |
| E18 | LPN | Documented verbal inappropriateness with resident. |
| E20 | LPN | Confirmed respiratory care deficiencies. |
| E21 | LPN | Confirmed oxygen equipment not changed as ordered. |
| E22 | LPN | Confirmed refusal of care and incomplete care plan. |
| E16 | Clinical Liaison | Confirmed lack of transfer notification. |
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