Deficiencies (last 3 years)
Deficiencies (over 3 years)
16.3 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
85% worse than Delaware average
Delaware average: 8.8 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Annual Inspection
Deficiencies: 2
Date: 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.
Deficiencies (2)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, resulting in an avoidable unstageable pressure ulcer causing harm.
Failure to provide enough food/fluids to maintain a resident's health, resulting in harm due to dehydration and related complications.
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
Complaint Investigation
Deficiencies: 2
Date: Oct 22, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide appropriate pressure ulcer care and adequate hydration to a resident, resulting in actual harm.
Complaint Details
The complaint investigation focused on one resident (R1) who developed an avoidable unstageable pressure ulcer and suffered harm due to inadequate wound care and hydration. The findings were substantiated with clinical record reviews, interviews, and hospital documentation confirming harm.
Findings
The facility failed to provide necessary treatment and prevention for pressure ulcers, leading to an unstageable bilateral buttocks wound causing harm. Additionally, the facility did not ensure adequate hydration for the resident, resulting in acute kidney injury and metabolic acidosis requiring hospitalization.
Deficiencies (2)
F686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing, resulting in an unstageable bilateral buttocks pressure ulcer causing harm.
F692: The facility failed to provide enough food and fluids to maintain the resident's health, resulting in dehydration, acute kidney injury, and metabolic acidosis.
Report Facts
Fluid intake: 600
Fluid output: 2050
BUN lab value: 155
Creatinine lab value: 9.1
Pressure ulcer size: 28
Pressure ulcer size: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E4 | LPN | Confirmed wound treatment and notification of wound care nurse; confirmed decreased intake and notification of unit manager and provider |
| E3 | Wound Care Nurse (WCN) | Assessed wounds, initiated low air loss mattress, and confirmed wound progression |
| E2 | Director of Nursing (DON) | Participated in exit conference and confirmed provider was not consulted regarding decreased intake |
| E6 | CNA | Confirmed resident dependency and wound presence; confirmed poor appetite and feeding efforts |
| E7 | CNA | Confirmed resident dependency and wound presence |
| E10 | Dietician | Reviewed nutritional status and intake but did not address hydration status |
Inspection Report
Routine
Census: 28
Deficiencies: 2
Date: 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.
Deficiencies (2)
Failure to perform hand hygiene between medication administrations and touching medications with bare hands.
Failure to wear gowns and follow transmission-based precautions when administering antibiotics and flushing PICC line tubing.
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
Complaint Investigation
Deficiencies: 7
Date: Jul 31, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding failure to complete PASRR referrals, inadequate care planning, pressure ulcer care, respiratory care, medication errors, infection control, and equipment safety at Delaware Bay Rehabilitation and Healthcare Center.
Complaint Details
The complaint investigation substantiated multiple deficiencies including failure to complete PASRR referrals, inadequate care planning, pressure ulcer prevention failures, respiratory care lapses, significant medication errors causing immediate jeopardy, infection control breaches, and unsafe kitchen equipment maintenance.
Findings
The facility was found deficient in multiple areas including failure to complete PASRR referrals for residents with new mental health diagnoses, incomplete care plans for hospice residents, inadequate pressure ulcer prevention, improper respiratory equipment handling, significant medication errors resulting in immediate jeopardy, lapses in infection prevention practices, and unsafe kitchen sanitizing equipment.
Deficiencies (7)
F0644: The facility failed to ensure new PASRR referrals were completed for residents R31 and R10 after new mental health diagnoses and medication changes.
F0656: The facility failed to develop a complete care plan for resident R3 to address hospice needs with measurable goals and timeframes.
F0686: The facility failed to turn and reposition resident R74 as ordered, risking pressure ulcer development and delayed healing.
F0695: The facility failed to ensure oxygen tubing and humidifier bottle were changed weekly for R18 and failed to store R98's BiPAP equipment in a protective bag.
F0760: The facility failed to prevent significant medication errors for residents R129 and R123, resulting in immediate jeopardy and hospitalizations.
F0880: The facility failed to ensure infection prevention practices were followed, including hand hygiene during medication administration and gown use when accessing PICC lines for residents R109 and R97.
F0908: The facility failed to maintain appropriate sanitizing chemical concentrations in kitchen sanitizer buckets and three compartment sink.
Report Facts
Residents reviewed for PASRR: 2
Residents reviewed for 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 observed: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E11 | Social Worker | Confirmed PASRR referral was not completed for R31. |
| E2 | Director of Nursing | Provided updated PASRR assessment for R31 and confirmed care plan and medication error findings. |
| E20 | Social Worker | Entered PASRR resubmission for R10 and was unaware of prior referral status. |
| E8 | Certified Nursing Assistant | Interviewed about repositioning resident R74. |
| E4 | Licensed Practical Nurse | Confirmed repositioning failure for R74 and replaced undated oxygen tubing for R18. |
| E13 | RN Educator / Staff Educator | Observed BiPAP bagging for R98 and provided medication error education. |
| E5 | Registered Nurse | Confirmed medication error for R129 and immediate reporting. |
| E17 | Licensed Practical Nurse | Administered wrong medication to R129 and reported error. |
| E12 | Registered Nurse (Agency) | Administered insulin to R123 outside parameters. |
| E18 | Licensed Practical Nurse | Observed failing hand hygiene and improper medication handling. |
| E19 | Agency Licensed Practical Nurse | Did not wear gown when accessing PICC line for R97. |
| E16 | Dietary Supervisor | Tested sanitizer chemical concentration in kitchen. |
Inspection Report
Routine
Deficiencies: 7
Date: 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.
Deficiencies (7)
Failure to ensure new PASRR referrals were completed upon new mental health diagnoses and psychotropic medication starts for residents R31 and R10.
Failure to develop a complete care plan addressing hospice needs for resident R3.
Failure to turn and reposition resident R74 to promote healing of a pressure ulcer.
Failure to ensure oxygen tubing and humidifier bottle were changed weekly for R18 and improper storage of BiPAP equipment for R98.
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.
Failure to follow infection prevention practices including hand hygiene during medication administration and lack of gown use when accessing PICC line for resident R97.
Failure to maintain appropriate sanitizing chemical concentration in kitchen sanitizer buckets and three compartment sink.
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: 15
Date: Aug 9, 2024
Visit Reason
Routine inspection of Delaware Bay Rehabilitation and Healthcare Center to assess compliance with regulatory standards including PASARR screening, admission assessments, discharge procedures, ADL care, continence care, nutrition, medication management, infection control, and kitchen safety.
Findings
The facility had multiple deficiencies including failure to complete PASARR Level II screenings for residents with serious mental disorders, admission assessments performed by LPNs instead of RNs, missing discharge summaries, inadequate ADL and continence care, failure to address significant weight loss, inappropriate psychotropic medication use, incomplete infection prevention and control program, and unsafe kitchen equipment maintenance.
Deficiencies (15)
F0644: The facility failed to ensure referrals for PASARR Level II screenings were completed for residents with serious mental disorders.
F0645: The facility failed to maintain accurate and current PASARR Level I screenings for residents with mental disorders or intellectual disabilities.
F0658: The facility failed to ensure admission assessments and progress notes were completed by RNs as required, with LPNs performing these duties for multiple residents.
F0661: The facility failed to provide a discharge summary including a reaccounting of stay and pre-discharge medication review for one resident.
F0677: The facility failed to provide necessary grooming services for a resident dependent on staff for ADLs, resulting in long nails with debris.
F0690: The facility failed to provide services to restore bladder continence and establish toileting programs for residents with incontinence.
F0692: The facility failed to recognize and address significant weight loss in a resident, delaying nutritional interventions.
F0711: The facility failed to ensure physician visits included evaluation and documentation of a resident's significant weight loss and nutritional status.
F0757: The facility failed to ensure residents were free from unnecessary medications, including failure to report increased lethargy and daytime sleepiness to providers.
F0758: The facility failed to implement appropriate psychotropic medication monitoring, including lack of diagnosis documentation, failure to limit PRN use, and inadequate monitoring of antipsychotic use.
F0803: The facility failed to ensure dietician-approved menus were followed and residents received the selected food items.
F0812: The facility failed to store, prepare, and serve food in a manner that prevents foodborne illness, including thawing frozen food improperly, missing date labels, rusted shelves, and inadequate sanitizer levels.
F0880: The facility failed to establish and maintain an infection prevention and control program, including failure to initiate enhanced barrier precautions for residents with MDRO colonization and inadequate infection surveillance documentation.
F0881: The facility failed to implement an antibiotic stewardship program that monitored culture results to ensure appropriate antibiotic use for correct indications and durations.
F0908: The facility failed to maintain essential kitchen equipment in safe operating condition, including significant ice build-up on a damaged protective grate in the walk-in freezer.
Report Facts
Weight loss: 14.6
Bed baths received: 32
Bed baths received: 29
Incontinence episodes: 9
Incontinence episodes: 27
Incontinence episodes: 39
Incontinence episodes: 8
Duration of missing enhanced barrier precautions: 94
Duration of missing enhanced barrier precautions: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E12 | MD | Named in findings related to failure to address weight loss, psychotropic medication monitoring, infection control, and antibiotic stewardship. |
| E13 | PA | Named in findings related to medication orders, infection control, and antibiotic stewardship. |
| E7 | Dietician | Named in findings related to nutrition assessment and failure to address weight loss. |
| E1 | NHA | Named as participant in exit conferences. |
| E2 | ADON | Named as participant in exit conferences and infection control communication. |
| E3 | QA RN | Named as participant in exit conferences. |
| E4 | MDS LPN | Named as participant in exit conferences and continence care interviews. |
| E11 | CNA | Named in findings related to ADL care and missing meal items. |
| E31 | Infection Preventionist | Named in infection control program deficiencies and surveillance. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: 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.
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.
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.
Deficiencies (4)
Failed to promote resident dignity by not covering urinary catheter bags and verbal inappropriate behavior by staff.
Failed to timely report suspected abuse to the Administrator and State Agency.
Failed to provide timely notification to residents or representatives before transfer or discharge.
Failed to provide appropriate treatment and care by not consistently applying lymphedema pumps as prescribed.
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
Date: 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.
Deficiencies (10)
Failure to promote resident dignity for two residents related to verbal interactions and urinary catheter privacy.
Failure to provide timely written notification to residents or representatives before transfer or discharge for two residents.
Failure to update care plan to include refusal of care for one resident.
Failure to provide nail care for dependent resident due to refusals and lack of documentation.
Failure to consistently apply prescribed lymphedema pumps for one resident with missed treatment opportunities.
Failure to ensure oxygen humidifier bottle and tubing were changed weekly and tubing/nasal cannula stored properly for two residents.
Lack of evidence of annual performance evaluation for one CNA.
Failure to ensure safe sanitary storage of food, protect food quality, and maintain consistent food temperature logs.
Failure to ensure attendance of required members, specifically Medical Director, at two of three quarterly Quality Assessment and Assurance meetings.
Failure to ensure required trainings on abuse, neglect, exploitation, and dementia management were completed for three staff members.
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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