Inspection Reports for Kentmere Rehabilitation and Healthcare Center
1900 Lovering Avenue, Wilmington, DE, 19806
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 22, 2024, identified deficiencies related to residents’ rights, abuse and neglect, medication administration, care planning, pharmacy services, food safety, and equipment safety. Earlier inspections showed a pattern of issues including staffing shortages, failure to provide timely emergency care, infection control lapses, and deficiencies in resident care and documentation. Complaint investigations substantiated abuse, neglect, and misappropriation of property, with staff disciplinary actions noted, but no fines or license actions were listed in the available reports. Prior complaint investigations were mostly unsubstantiated or focused on infection control and staffing concerns. The facility’s deficiencies have persisted over time with no clear trend of improvement.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
16.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
90% worse than Delaware average
Delaware average: 8.8 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
94 residents
Based on a November 2024 inspection.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Dec 13, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to timely report allegations of abuse, failure to respond appropriately to alleged violations, inadequate supervision to prevent accidents, and pest control issues within the facility.
Complaint Details
The complaint investigation revealed failures in timely reporting of abuse allegations involving Residents #11, #19, #18, #34, and #37. Staff failed to report incidents within the required two-hour timeframe. Licensed Practical Nurse #20 failed to follow notification procedures and was no longer employed. The facility also failed to interview all relevant staff and involved persons during abuse investigations for Residents #34 and #93. Additionally, inadequate supervision led to a fall of Resident #110 resulting in a fractured femur and subsequent death. Broken glass hazard was identified in Resident #62's room but was not promptly removed. Rodent infestation was observed on the 3rd floor with evidence of droppings and a live mouse sighting. The facility acknowledged ongoing pest control issues and had recently changed pest control companies.
Findings
The facility failed to timely report allegations of abuse involving multiple residents, failed to interview all persons involved or knowledgeable in abuse investigations, failed to provide adequate supervision to prevent a resident fall resulting in injury and death, failed to remove accident hazards such as broken glass in a resident's room, and failed to maintain an effective pest control program to address rodent infestation on the 3rd floor.
Deficiencies (5)
Failure to timely report allegations of abuse to the state survey agency involving multiple residents.
Failure to interview all persons identified as involved or with knowledge of an occurrence for abuse investigations.
Failure to provide supervision to prevent a fall resulting in injury and death of a resident.
Failure to identify and remove accident hazard (broken glass) in a resident's room.
Failure to maintain an effective pest control program to address rodent infestation on the 3rd floor.
Report Facts
Residents reviewed for abuse: 7
Residents affected by untimely abuse reporting: 5
Residents affected by failure to interview all involved persons: 2
Resident fall resulting in injury and death: 1
Rooms on dementia unit: 25
Floors in facility: 4
Floor with rodent infestation: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #20 | Licensed Practical Nurse | Failed to follow notification process for allegations of abuse and was no longer employed |
| Certified Nurse Aide #16 | Certified Nurse Aide | Turned back during care leading to resident fall and injury |
| Director of Nursing | Director of Nursing | Interviewed regarding abuse reporting failures and fall incident |
| Executive Director | Executive Director | Interviewed regarding abuse reporting failures, fall incident, and pest control issues |
| Licensed Practical Nurse #8 | Licensed Practical Nurse | Alleged to have caused bruising to Resident #34 |
| Speech Language Pathologist | Speech Language Pathologist | Interviewed regarding Resident #34 incident |
| Licensed Practical Nurse #13 | Licensed Practical Nurse | Wrote nurse's note on Resident #93's injury |
| Registered Nurse #12 | Registered Nurse | Not interviewed during Resident #93 investigation |
| Certified Nurse Aide #1 | Certified Nurse Aide | Reported rodent sightings and interviewed about pest control |
| Director of Maintenance | Director of Maintenance | Interviewed regarding pest control and rodent sightings |
Inspection Report
Routine
Deficiencies: 16
Date: Nov 22, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication administration, abuse prevention, and facility operations at Kentmere Rehabilitation and Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to ensure informed consent for psychotropic medications, allowing self-administration of medication without proper assessment, abuse and neglect incidents, misappropriation of resident property, delayed reporting of abuse allegations, inaccurate resident assessments, inconsistent provision of activities of daily living, failure to notify physicians of new wounds, improper medication administration practices, inadequate foot and nail care, failure to provide adaptive equipment and splinting as ordered, inadequate supervision to prevent accidents, insufficient staff competencies for dementia care, failure to follow narcotic count procedures, failure to follow menu portion sizes, failure to wear beard guards in food preparation, and failure to maintain essential equipment.
Deficiencies (16)
Failed to ensure risks vs benefits for psychotropic medications were obtained for one resident.
Failed to allow one resident to self-administer cough drops per physician order due to lack of assessment.
Failed to protect three residents from abuse including physical and verbal abuse by staff.
Failed to protect two residents from misappropriation of property by a staff member.
Failed to timely report an allegation of potential abuse to the State Survey Agency.
Failed to ensure one resident had an accurate Minimum Data Set assessment reflecting a fall.
Failed to provide consistent activities of daily living including oral hygiene and showers for two residents.
Failed to notify physician and obtain orders for treatment of a new wound and failed to obtain blood pressure prior to administering hypertensive medication for two residents.
Failed to provide nail care to one resident resulting in uncut toenails extending beyond toes.
Failed to provide adaptive equipment and consistent splinting as ordered for two residents.
Failed to provide adequate supervision and assistance to prevent accidents for one resident.
Failed to ensure sufficient staff competencies and skills to meet behavioral health needs resulting in harm to one resident.
Failed to ensure narcotic count sheets were properly documented on medication carts for multiple shifts.
Failed to ensure menus were followed related to portion size for residents on mechanical soft and regular diets.
Failed to ensure beard guards were worn during food production by kitchen staff with beards.
Failed to ensure one resident's wheelchair was functioning properly.
Report Facts
Sample residents reviewed: 40
Residents affected by abuse: 3
Residents affected by misappropriation: 2
Residents affected by narcotic count deficiencies: 5
Residents affected by menu portion size issues: 4
Residents affected by beard guard noncompliance: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN6 | Registered Nurse | Named in physical abuse incident with Resident R103 |
| CNA12 | Certified Nurse Aide | Named in verbal abuse incident with Resident R39 |
| CNA16 | Certified Nurse Aide | Terminated for misappropriation of resident property |
| CNA1 | Certified Nurse Aide | Named in abuse incident with Resident R108 |
| LPN1 | Licensed Practical Nurse | Involved in abuse investigation and wound assessment for Resident R108 |
| LPN7 | Licensed Practical Nurse | Observed administering medication without obtaining blood pressure for Resident R109 |
| CNA6 | Certified Nurse Aide | Transferred Resident R102 alone causing fall |
| CNA2 | Certified Nurse Aide | Reported broken wheelchair for Resident R36 |
| UM1 | Unit Manager | Interviewed regarding narcotic sheet monitoring and resident care |
| DON | Director of Nursing | Interviewed multiple times regarding various deficiencies and investigations |
| DM | Dietary Manager | Interviewed regarding menu portion sizes and food safety |
| RD | Registered Dietician | Interviewed regarding portion sizes and nutritional needs |
| DOR | Director of Rehabilitation | Interviewed regarding wheelchair and adaptive equipment for Resident R36 |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Nov 22, 2024
Visit Reason
The inspection was conducted due to multiple allegations of abuse, neglect, misappropriation, and failure to report suspected abuse in a timely manner at Kentmere Rehabilitation and Healthcare Center.
Complaint Details
The complaint investigation involved allegations of abuse and neglect for multiple residents (R103, R39, R105, R108, R17, R95, R102). Several allegations were substantiated, including physical abuse by RN6, verbal intimidation and disrespect by CNAs, misappropriation of resident property by CNA16, failure to timely report abuse for R108, and inadequate dementia care by CNA1. Staff involved were suspended and/or terminated.
Findings
The facility failed to protect residents from abuse by staff, including physical and verbal abuse, misappropriation of resident property by a CNA, failure to timely report suspected abuse to the State Survey Agency, and failure to provide adequate supervision and dementia care. Several staff members were terminated following investigations. Residents sustained injuries including bruising, skin tears, and emotional distress.
Deficiencies (5)
Failure to protect residents from abuse including physical and verbal abuse by staff.
Failure to protect residents from misappropriation of property by a Certified Nurse Aide.
Failure to timely report suspected abuse to the State Survey Agency within required timeframe.
Failure to provide adequate assistance and supervision to prevent accidents, including improper use of mechanical lift.
Failure to ensure staff possessed competencies and skills to meet behavioral health needs, resulting in harm to a resident with dementia.
Report Facts
Residents reviewed for abuse: 6
Residents affected by deficiencies: 40
Dates of incidents: Nov 23, 2023
Dates of incidents: Oct 14, 2023
Dates of incidents: Feb 22, 2024
Dates of incidents: Oct 13, 2023
Unauthorized charges: 8
Unauthorized charges: 1
Skin tear size: 1.2
Skin tear size: 0.5
Bruising size: 4.5
Bruising size: 15
Bruising size: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN6 | Registered Nurse | Named in physical abuse incident involving resident R103; suspended and terminated. |
| CNA12 | Certified Nurse Aide | Named in verbal abuse and threats toward resident R39; resigned after investigation. |
| CNA13 | Certified Nurse Aide | Named in verbal intimidation and disrespectful conduct toward resident R105; terminated. |
| CNA16 | Certified Nurse Aide | Named in misappropriation of resident property involving residents R17 and R95; terminated. |
| CNA1 | Certified Nurse Aide | Named in abuse causing skin tears and bruising to resident R108; terminated. |
| Director of Nursing | Director of Nursing | Interviewed regarding investigations and facility policies. |
| MDS Coordinator | MDS Coordinator | Reported abuse allegations and confirmed failure to timely report to SSA. |
| LPN7 | Licensed Practical Nurse | Confirmed investigation findings related to CNA12 and resident R39. |
| Human Resources | Human Resources | Defined verbal intimidation as verbal abuse in investigation of resident R105. |
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 14
Date: Nov 22, 2024
Visit Reason
A Recertification and Complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Delaware, Department of Health and Social Services, Division of Health Care Quality. The survey was conducted from 11/19/24 to 11/22/24 to assess compliance with 42 CFR 483 subpart B.
Complaint Details
The complaint investigation was substantiated with findings of abuse, neglect, misappropriation of property, and failure to protect residents. Specific incidents included physical abuse, verbal intimidation, theft of resident property, and failure to report allegations timely. Staff disciplinary actions and terminations were noted.
Findings
The facility was found not to be in compliance with 42 CFR 483 subpart B. Deficiencies were identified related to residents' rights to be informed and make treatment decisions, freedom from abuse and neglect, accuracy of assessments, quality of care, pharmacy services, food safety, and safe operating conditions of equipment. Several residents were placed at risk due to failures in medication administration, abuse investigations, self-administration of medications, and care planning.
Deficiencies (14)
Failure to ensure residents were informed of risks and benefits of psychotropic medications, placing residents at risk of uninformed care decisions.
Failure to ensure one resident was allowed to self-administer cough drops per physician order, violating resident rights.
Failure to ensure three residents were free from abuse, neglect, and exploitation, including physical abuse and misappropriation of property.
Failure to report alleged violations of abuse, neglect, exploitation, or mistreatment immediately and within required timeframes.
Failure to protect residents from misappropriation of property, including theft of credit card and money.
Failure to ensure accuracy of resident assessments, leading to inaccurate federal reimbursements and care planning.
Failure to provide consistent activities of daily living (ADLs) care, including oral hygiene and showers, placing residents at risk of diminished quality of life.
Failure to ensure proper foot care and podiatry consults for residents, risking mobility and health complications.
Failure to ensure quality of care, including skin care, medication administration, and wound care, resulting in untreated wounds and risk of infection.
Failure to ensure sufficient staff competencies and training in dementia care, resulting in resident harm and inadequate care.
Failure to provide pharmacy services including narcotic count accuracy and medication storage, risking drug diversion.
Failure to ensure menus and nutritional adequacy, including proper portion sizes and diet consistency, risking resident nutrition.
Failure to maintain safe operating condition of patient care equipment, including broken wheelchair, risking resident safety.
Failure to ensure food safety practices including staff hygiene and food preparation, risking contamination.
Report Facts
Survey Census: 94
Sample Size: 40
Supplemental Residents: 10
Deficiencies cited: 16
Plan of Correction Completion Dates: Dates range from 2025-01-29 to 2025-01-29 for various deficiencies
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide CNA12 | Named in verbal intimidation and abuse allegations | |
| Licensed Practical Nurse LPN7 | Confirmed allegations and participated in investigation | |
| Certified Nurse Aide CNA16 | Terminated following investigation of theft and misappropriation | |
| Director of Nursing DON | Director of Nursing | Interviewed regarding abuse allegations and investigation |
| Social Services Director SSD | Social Services Director | Provided statements regarding resident interactions and abuse |
| Licensed Practical Nurse LPN1 | Documented skin tear and participated in investigation | |
| Certified Nurse Aide CNA1 | Reported skin tear and resident abuse incident | |
| Registered Nurse RN5 | Observed wound care and participated in resident care | |
| Certified Nurse Aide CNA2 | Reported on resident care and abuse incidents | |
| Dietary Manager DM | Dietary Manager | Interviewed regarding food portion sizes and meal service |
| Registered Dietician RD | Registered Dietician | Interviewed regarding nutritional adequacy and meal portions |
Inspection Report
Annual Inspection
Census: 99
Deficiencies: 11
Date: Oct 12, 2023
Visit Reason
An unannounced annual and complaint survey was conducted at Kentmere Rehabilitation And Healthcare Center from October 9 through October 12, 2023, to assess compliance with federal and state regulations including emergency preparedness and long-term care requirements.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified in personnel documentation, transfer and discharge notices, bed rail safety, medication management, food safety, resident assessments, and binding arbitration agreements among others. No residents were harmed by the deficient practices noted.
Deficiencies (11)
Facility failed to provide documentation verifying annual influenza immunization or refusal for 6 out of 10 employees reviewed.
Personnel records lacked evidence of criminal background checks, mandatory drug testing, and adult abuse registry checks for 6 out of 10 employees reviewed.
Facility failed to ensure one employee received pre-employment tuberculosis screening.
Facility failed to ensure two of three residents and/or their representatives were provided with timely and complete transfer/discharge notices.
Facility failed to ensure bed rail safety assessments and informed consents were completed for two residents.
Facility failed to ensure performance reviews were completed every 12 months for five nurse aides.
Facility failed to ensure medication carts were free of loose pills and properly secured.
Facility failed to ensure regular in-service education for nurse aides was completed annually.
Facility failed to ensure food safety requirements were met, including proper labeling, storage, and dishwasher temperature monitoring.
Facility failed to maintain accurate and timely resident assessments and care plans for multiple residents.
Facility failed to ensure binding arbitration agreements were properly executed and explained to residents and representatives.
Report Facts
Facility census: 99
Sample size: 28
Supplemental residents: 24
Employees reviewed for influenza documentation: 10
Employees lacking background checks: 6
Residents reviewed for transfer notices: 3
Nurse aides reviewed for performance evaluations: 5
Residents reviewed for assessments: 28
Residents signed arbitration agreements: 99
Inspection Report
Routine
Deficiencies: 12
Date: Oct 12, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident transfer notifications, bed hold policies, resident assessments, bed rail use, nurse aide performance and training, medication storage and labeling, food safety, medical record accuracy, and arbitration agreements.
Findings
The facility was found deficient in multiple areas including failure to provide timely written transfer and bed hold notices to residents and their representatives, inaccurate resident assessments, lack of documented safety assessments and informed consent for bed rail use, failure to conduct annual nurse aide performance reviews and in-service training, improper medication storage and presence of loose pills, inadequate food storage and sanitation practices including dishwasher temperature issues, incomplete nursing documentation for residents, and deficiencies in the arbitration agreement process including inadequate explanation and missing rescission period and venue clause.
Deficiencies (12)
Failure to provide timely written notice of transfer and discharge to residents and their representatives.
Failure to notify residents or representatives in writing of bed hold policy upon transfer/discharge to hospital.
Failure to provide accurate resident assessment regarding Level II PASARR on admission MDS.
Failure to resubmit PASARR upon new mental health diagnosis.
Failure to assess safety risks, advise resident/representative of risks/benefits, obtain informed consent, and maintain bed rails properly.
Failure to complete annual performance reviews for nurse aides.
Failure to ensure medication carts free of loose pills and proper medication storage; medication found in wrong resident's room.
Failure to store food in sanitary manner, maintain dishwasher at proper sanitizing temperatures, maintain sanitizer at correct levels, and keep food storage containers clean.
Failure to maintain accurate medical records including nursing documentation of lab results and ADL tasks.
Failure to allow 30 days rescission period and fully explain arbitration agreement to residents and representatives.
Failure to include mutually convenient venue clause in arbitration agreement.
Failure to ensure nurse aides receive at least 12 hours of in-service training per year.
Report Facts
Residents affected by arbitration agreement deficiency: 34
Dishwasher temperature: 136
Dishwasher temperature: 141
Dishwasher temperature: 175
Dishwasher temperature: 177
Sanitizer level: 0
CNA performance reviews missing: 5
CNA in-service training hours missing: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed no written discharge or bed hold notices were given; aware arbitration rescission period was incorrect; aware arbitration venue clause missing; acknowledged dishwasher temperature issue | |
| Director of Admissions | Explained transfer/discharge and bed hold notice practices; explained arbitration agreement to residents | |
| Director of Nursing | Confirmed expectations for accurate MDS assessments, restorative nursing documentation, and CNA documentation; confirmed medication cart and dishwasher deficiencies | |
| Staff Development Coordinator | Verified CNAs did not receive required annual in-service training hours | |
| Registered Nurse 1 | RN | Confirmed medication left in wrong resident's room |
| Licensed Practical Nurse 1 | LPN | Unaware of abnormal lab results for resident |
| Dietary Manager | Verified food storage and dishwasher temperature deficiencies | |
| Sous-Chef 1 | Verified soiled flour container and improper use of plate to scoop flour | |
| Human Resources/Payroll Coordinator | Verified missing annual CNA performance reviews | |
| Certified Nursing Assistant 4 | CNA | Confirmed missing ADL documentation and in-service training hours |
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 4
Date: Apr 25, 2022
Visit Reason
An unannounced complaint and extended survey was conducted from April 13, 2022 to April 25, 2022 by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection.
Complaint Details
The complaint investigation found that one resident (R1) was not provided CPR despite being a Full Code and unresponsive. The facility failed to report the incident to the State Survey Agency within the required timeframe. The allegation of neglect was substantiated as the facility failed to ensure timely reporting and appropriate emergency response.
Findings
The facility was found out of compliance with staffing requirements and failed to provide adequate staffing levels for at least three days. Additionally, the facility failed to report an alleged violation of neglect immediately and failed to perform CPR on a resident who was a Full Code. Deficiencies included failure to maintain minimum staffing hours, failure to report incidents timely, and failure to provide basic life support including CPR.
Deficiencies (4)
Facility failed to provide staffing at a level of at least 3.28 hours of direct care per resident per day for three days.
Failure to report alleged violation of neglect immediately, but not later than 2 hours after the allegation was made.
Failure to provide basic life support including CPR to a resident who was a Full Code.
Failure to ensure licensed nurses had the skill sets necessary to provide care when a resident had a change of condition and was unresponsive.
Report Facts
Facility census: 98
Survey sample size: 5
Staffing hours per resident per day: 3.28
Staffing hours recorded: 2.69
Staffing hours recorded: 3.15
Staffing hours recorded: 3.09
Time to report incident: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E5 | Registered Nurse (RN) | Named in failure to perform CPR and failure to report incident |
| E8 | Physician/Medical Director | Named in failure to perform CPR and incident reporting |
| E6 | Licensed Practical Nurse (LPN) | Named in failure to assess resident and check code status |
| E7 | Certified Nurse Assistant (CNA) | Named in notifying nursing staff of resident unresponsiveness |
| E4 | Infection Control/Staff Development | Involved in education and monitoring corrective actions |
| E1 | Nursing Home Administrator (NHA) | Participated in exit conference and review of findings |
| E2 | Director of Nursing (DON) | Participated in exit conference and review of findings |
Inspection Report
Follow-Up
Census: 86
Deficiencies: 0
Date: Jan 27, 2022
Visit Reason
An unannounced follow-up survey was conducted for the annual and complaint survey ending December 9, 2021, to assess compliance at the facility.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 Subpart B Requirements for Long Term Care Facilities as of January 7, 2022. No deficiencies were identified at the time of the survey.
Report Facts
Survey sample size: 9
Inspection Report
Annual Inspection
Census: 93
Deficiencies: 12
Date: Dec 9, 2021
Visit Reason
An unannounced annual, complaint, and emergency preparedness survey was conducted at the facility from December 1, 2021 through December 9, 2021 to assess compliance with federal and state regulations.
Findings
The survey identified multiple deficiencies related to resident care, infection control, emergency preparedness, and facility administration. Key issues included failure to notify maintenance of a broken call bell, inadequate resident self-determination processes, failure to post required information, grievances handling deficiencies, abuse and neglect reporting failures, respiratory care shortcomings, food safety violations, and infection control lapses during a COVID-19 outbreak.
Deficiencies (12)
Failure to notify maintenance staff of a broken call bell and failure to provide frequent checks on the call bell.
Failure to ensure resident self-determination rights were upheld, including making choices about activities and care.
Failure to post required information including names and contact information of state agencies and grievance procedures.
Failure to maintain survey results and complaint investigation reports for the past three years in a binder accessible to residents and representatives.
Failure to implement a grievance policy that includes procedures for filing grievances anonymously and identifying a grievance official.
Failure to identify and report allegations of neglect and abuse timely and failure to provide appropriate education to staff.
Failure to provide adequate assistance with toileting and failure to report allegations of neglect related to toileting.
Failure to provide appropriate respiratory care and ensure oxygen tubing and humidifier bottles were changed weekly.
Failure to ensure food was stored, prepared, and served in a sanitary manner, including ice machine covered with biofilm.
Failure to administer the facility in a manner that enables effective infection control practices during a COVID-19 outbreak.
Failure to maintain attendance at Quality Assurance meetings and failure to correct attendance issues.
Failure to maintain an effective infection prevention and control program including staff education and PPE usage during COVID-19 outbreak.
Report Facts
Facility census: 93
Survey sample size: 45
Deficiency completion dates: Various completion dates listed for plans of correction, e.g., 1/7/2022, 12/30/2021
Number of staff fit tested: 7
Number of residents audited: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E11 | Nursing Home Administrator (NHA) | Interviewed during exit conference and involved in findings review |
| E2 | Director of Nursing (DON) | Interviewed during exit conference and involved in findings review |
| E6 | Director of Social Services (DSS) and Grievance Officer | Interviewed regarding grievances and complaint investigations |
| E26 | Maintenance Director | Interviewed regarding broken call bell maintenance |
| E27 | Certified Nurse Aide (CNA) | Interviewed regarding call bell issues |
| E4 | RN Infection Control Practitioner (ICP) | Interviewed regarding infection control and COVID-19 outbreak |
| E20 | Certified Nurse Aide (CNA) | Observed wearing surgical mask and involved in COVID-19 unit observations |
| E14 | Certified Nurse Aide (CNA) | Observed residents and infection control compliance |
| E15 | RN Unit Manager | Interviewed regarding resident care and shower preferences |
| E16 | Licensed Practical Nurse (LPN) | Interviewed regarding resident care and shower preferences |
| E17 | Certified Nurse Aide (CNA) | Interviewed regarding resident shower frequency |
| E18 | Director of Rehabilitation | Attended interdisciplinary care plan meeting |
| E21 | Staff Educator | Involved in infection control education and COVID-19 outbreak response |
| E31 | Licensed Practical Nurse (LPN) | Interviewed regarding N95 training and fit testing |
Inspection Report
Complaint Investigation
Deficiencies: 11
Date: Dec 9, 2021
Visit Reason
The inspection was conducted based on complaints and allegations related to resident rights, grievance handling, abuse reporting, care planning, activities of daily living assistance, respiratory care, infection control, and facility administration during a COVID-19 outbreak.
Complaint Details
The complaint investigation included substantiated findings of failure to honor resident choice, failure to resolve grievances, failure to timely report abuse and neglect, failure to provide adequate care and supervision, and failure to implement infection control during a COVID-19 outbreak.
Findings
The facility was found deficient in multiple areas including failure to honor resident choice for bathing frequency, failure to resolve grievances promptly, failure to timely report abuse and neglect, failure to develop baseline care plans timely, failure to ensure complete interdisciplinary care planning, failure to provide adequate assistance with activities of daily living, failure to maintain a safe environment to prevent accidents, failure to provide appropriate respiratory care, failure to maintain sanitary food storage, failure to ensure effective facility administration during a COVID-19 outbreak, and failure to implement appropriate infection prevention and control practices including proper PPE use and staff fit-testing for N95 respirators.
Deficiencies (11)
Failed to ensure resident's right to make choices about bathing frequency; resident received showers twice a week despite preference for more frequent showers.
Failed to make prompt efforts to resolve grievances and failed to implement grievance policy including anonymous filing and grievance official identification.
Failed to timely report suspected abuse and neglect to the State Agency within required 2 hours.
Failed to develop baseline care plan within 48 hours of admission for newly admitted residents.
Failed to ensure care plan was prepared by interdisciplinary team including attending physician, nurse aide, and nutrition staff.
Failed to provide adequate assistance with activities of daily living including bathing and nail care for dependent residents.
Failed to maintain a safe environment free from accident hazards; resident fell while receiving toileting care by one staff instead of two as required.
Failed to provide appropriate respiratory care; oxygen tubing and humidifier bottle were not changed weekly and lacked physician order.
Failed to ensure food was stored, prepared, and served in a sanitary manner; ice machine filter was covered in biofilm.
Failed to administer the facility in a manner that enabled effective and efficient use of resources during a COVID-19 outbreak despite access to current guidance and resources.
Failed to provide and implement an infection prevention and control program; staff failed to wear appropriate PPE including N95 respirators, lacked fit-testing and training, COVID-19 unit was not discrete with dedicated staff, and residents were not physically distanced.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | NHA (Nursing Home Administrator) | Reviewed findings and participated in exit conferences |
| E2 | DON (Director of Nursing) | Reviewed findings and participated in exit conferences |
| E4 | ICP (Infection Control Practitioner) | Provided infection control guidance and participated in exit conferences |
| E6 | DSS and Grievance Officer | Involved in grievance handling and complaint investigations |
| E7 | CNA | Witnessed resident fall and involved in toileting care |
| E10 | RNAC | Confirmed lack of baseline care plan development |
| E13 | LPN | Observed wearing N95 without fit testing; involved in COVID-19 unit care |
| E15 | RN Unit Manager | Confirmed bathing preference system lacking |
| E20 | CNA | Observed providing care to both COVID positive and negative residents without proper PPE |
| E21 | Staff Educator | Observed PPE practices and participated in infection control |
| E24 | LPN | Designated COVID-19 unit staff with personal respirator |
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 3
Date: Aug 26, 2021
Visit Reason
An unannounced COVID-19 Focused Infection Control and Complaint surveys were conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection from August 23, 2021 through August 26, 2021.
Complaint Details
The survey was complaint-related and focused on infection control and urinary catheter care. The facility failed to implement recommended infection control practices and did not have adequate policies or procedures related to urinary catheter maintenance and infection prevention.
Findings
The facility was found to not be in compliance with 42 CFR §483.80 infection control regulations and had not implemented the CMS and CDC recommended practices to prepare for COVID-19. Deficiencies were identified related to comprehensive care plans for residents with urinary catheters and infection prevention and control practices.
Deficiencies (3)
Failure to develop comprehensive care plans for residents with urinary catheters, including measurable objectives and interventions to prevent urinary tract infections.
Failure to ensure appropriate treatment and services to prevent urinary tract infections for residents with indwelling catheters.
Failure to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
Report Facts
Survey sample residents: 9
Facility census: 94
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eileen Nodle | Administrator | Signed the initial statement of deficiencies on 9/17/2021 |
Inspection Report
Routine
Census: 95
Deficiencies: 0
Date: Jul 7, 2021
Visit Reason
An unannounced COVID-19 Focused Infection Control Survey was conducted by the State of Delaware Division of Health Care Quality from July 6, 2021 through July 7, 2021.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19. No deficiencies were identified at the time of the survey.
Report Facts
Survey sample size: 7
Inspection Report
Annual Inspection
Census: 102
Deficiencies: 7
Date: Jan 21, 2020
Visit Reason
An unannounced annual, complaint, and emergency preparedness survey was conducted at the facility from January 8, 2020 through January 21, 2020.
Complaint Details
The inspection included complaint investigation as part of the annual and emergency preparedness survey.
Findings
The survey identified multiple deficiencies related to grievance procedures, comprehensive care plans, quality of care, fall prevention, nutrition/hydration status maintenance, pain management, and labeling/storage of drugs and biologicals. Some deficiencies were cited as past noncompliance with no plan of correction required.
Deficiencies (7)
Failed to establish a system of filing grievance reports including lost and missing personal items and belongings.
Failed to develop comprehensive care plans for residents including measurable objectives and timeframes.
Failed to meet professional standards of quality in services provided or arranged by the facility.
Failed to ensure resident received care and services that are resident centered and meet professional standards regarding leave of absence policy.
Failed to ensure adequate supervision and assistance devices to prevent accidents for residents.
Failed to ensure pain management was provided consistent with professional standards of practice.
Failed to label drugs and biologicals in accordance with accepted professional principles and failed to remove expired medications.
Report Facts
Facility census: 102
Survey sample size: 43
Deficiency count: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator (NHA) | Named in discussions of findings and exit conference. |
| E2 | Director of Nursing (DON) | Named in discussions of findings and exit conference. |
| E23 | Assistant Director of Nursing (ADON) | Named in discussions of findings and exit conference. |
| E24 | Staff Educator | Named in discussions of findings and exit conference. |
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