Inspection Report Summary
The most recent inspection on June 2, 2025, identified deficiencies related to medication administration, hospice care, orthotic devices, and use of bed rails. Earlier inspections showed a pattern of issues including medication errors, care planning, abuse prevention, food safety, and incident reporting. Complaint investigations substantiated failures in timely reporting and abuse prevention, including a prior substantiated complaint about delayed CPR response. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s deficiencies have persisted over time with recurring themes in medication management and resident care, indicating ongoing challenges.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
14.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
61% worse than Delaware average
Delaware average: 8.8 deficiencies/yearDeficiencies per year
32
24
16
8
0
Census
Latest occupancy rate
79 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Census: 79
Deficiencies: 5
Jun 2, 2025
Visit Reason
An unannounced follow-up survey to the Annual Complaint Survey ending on March 26, 2025, was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection from May 28, 2025 through June 2, 2025.
Findings
The facility was found to not be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care as of June 2, 2025. Deficiencies included failure to follow physician's orders for hospice care, failure to provide orthotic devices as ordered, failure to provide pharmaceutical services meeting residents' needs, and failure to ensure residents were free from significant medication errors.
Severity Breakdown
F 684: 1
F 688: 1
F 700: 1
F 755: 1
F 760: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to follow a physician's order to ensure a resident received scheduled doses of olodaterol HCL inhalation aerosol solution. | F 684 |
| Failure to ensure a resident with limited mobility received appropriate orthotic devices (splints) as ordered. | F 688 |
| Failure to obtain consents from residents or representatives before using bed rails/enablers. | F 700 |
| Failure to provide pharmaceutical services to meet the needs of residents, including medication availability and proper documentation. | F 755 |
| Failure to ensure residents were free from significant medication errors, including administration of wrong medications. | F 760 |
Report Facts
Sample size: 19
Residents present: 79
Deficiency count: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator (NHA) | Reviewed findings during exit conference |
| E2 | Director of Nursing (DON) | Confirmed hospice provider signature review and audit processes |
| E3 | Registered Nurse (RN) | Confirmed hospice nurse responsibilities and medication administration |
| E4 | Unit Manager (UM) | Confirmed hospice nurse responsibilities and medication administration |
| E5 | Licensed Practical Nurse (LPN) | Confirmed medication availability and documentation |
| E7 | Licensed Practical Nurse (LPN) | Involved in medication error incident and received education |
| E9 | Certified Nursing Assistant (CNA) | Confirmed splint application practices |
| E10 | Licensed Practical Nurse (LPN) | Confirmed splint application practices |
Inspection Report
Annual Inspection
Census: 75
Deficiencies: 30
Mar 26, 2025
Visit Reason
An unannounced annual and complaint survey was conducted at the facility from March 6, 2025, through March 26, 2025, to assess compliance with state and federal regulations.
Findings
The survey identified multiple deficiencies related to food service environment, incident reporting, medication administration, resident dignity, abuse prevention, and care planning. The facility failed to provide a safe working environment for food service staff, timely incident reporting, and adequate medication administration oversight. Several residents were found to be at risk due to inadequate care and safety measures.
Complaint Details
The survey included complaint investigations related to falls, abuse, neglect, medication errors, and resident safety. Several allegations were substantiated including failure to report incidents timely, failure to prevent abuse and neglect, and failure to provide adequate care.
Severity Breakdown
SS=D: 4
SS=E: 5
SS=G: 1
Deficiencies (30)
| Description | Severity |
|---|---|
| Dumpster door had a gap large enough for rodents to enter the building. | — |
| Facility failed to provide a safe working environment for food service staff and a vermin proof environment for food storage and preparation. | — |
| Facility failed to have incident reports completed for unwitnessed falls and failed to report incidents timely to the State Agency. | — |
| Facility failed to report medication errors timely and failed to educate staff on reporting requirements. | — |
| Resident dignity was not maintained; resident was transported without a blanket covering legs and feet. | SS=D |
| Facility failed to provide special needs for a larger bed for a resident and failed to accommodate residents over 300 pounds. | SS=D |
| Facility failed to prevent abuse and neglect; staff failed to report and investigate allegations timely. | SS=E |
| Facility failed to ensure residents were free from significant medication errors. | SS=E |
| Facility failed to ensure residents were free from abuse and neglect. | SS=E |
| Facility failed to ensure residents received appropriate respiratory care including oxygen and tracheostomy care. | SS=D |
| Facility failed to ensure medication administration was timely and accurate; medication errors were not reported timely. | — |
| Facility failed to ensure bed rails were assessed and consent obtained prior to installation. | — |
| Facility failed to ensure nursing staff had competencies to meet residents' needs including medication administration and IV therapy. | — |
| Facility failed to ensure physician reviewed residents' total program of care including medications and treatments. | — |
| Facility failed to ensure residents were free of significant medication errors. | SS=E |
| Facility failed to ensure medication regimen review was conducted timely and irregularities addressed. | SS=D |
| Facility failed to ensure drug regimen review was conducted monthly by a licensed pharmacist. | SS=D |
| Facility failed to ensure medication orders were entered into the computer system timely and accurately. | — |
| Facility failed to ensure fall risk assessments and post-fall evaluations were completed timely and accurately. | — |
| Facility failed to ensure vital signs were monitored and documented timely after changes in condition. | — |
| Facility failed to ensure residents' care plans were updated and included interventions for identified risks. | — |
| Facility failed to ensure residents' medication administration records were accurate and complete. | — |
| Facility failed to ensure residents' medication allergies were identified and documented. | — |
| Facility failed to ensure residents' medication orders were reviewed and updated timely. | — |
| Facility failed to ensure residents' oxygen therapy was properly documented and monitored. | — |
| Facility failed to ensure residents' medication administration competencies were maintained. | — |
| Facility failed to ensure residents' medication administration was timely and accurate. | — |
| Facility failed to ensure residents' medication administration was properly documented and monitored. | — |
| Facility failed to ensure residents' medication administration was properly documented and monitored. | — |
| Facility failed to ensure residents' medication administration was properly documented and monitored. | — |
Report Facts
Facility census: 75
Survey sample: 35
Deficiency completion dates: Multiple deficiencies have completion dates ranging from 04/30/2025 to 05/10/2025
Residents reviewed for falls: 8
Residents reviewed for medication errors: 14
Residents reviewed for abuse/neglect: 14
Residents reviewed for medication: 14
Residents reviewed for nursing competencies: 14
Residents reviewed for vital signs: 7
Residents reviewed for bedrails: 4
Residents reviewed for medication regimen: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E36 | Maintenance Director | Named in finding related to dumpster door gap and rodent entry |
| E1 | CEO/LNHA | Named in review of incident reports and exit conference |
| E2 | DON | Named in review of incident reports, medication errors, and exit conference |
| E3 | SD/ICP | Named in exit conference and findings review |
| E20 | CNA | Named in incident report related to resident fall |
| E25 | CNA | Named in incident report documentation |
| E26 | LPN | Named in medication administration and bedrail findings |
| E27 | RN/ADON | Named in medication administration and incident report findings |
| E46 | Nurse | Named in medication administration competency findings |
| E48 | Nurse | Named in medication allergy and drug regimen review findings |
| E50 | CNA | Named in bedrail and medication administration findings |
| E65 | Nurse | Named in abuse/neglect investigation |
| E69 | Nurse | Named in abuse/neglect investigation |
| E82 | CNA | Named in abuse/neglect investigation |
| E83 | Nurse | Named in abuse/neglect investigation |
| E84 | Nurse | Named in medication administration findings |
| E85 | Nurse | Named in medication administration findings |
| E86 | Nurse | Named in medication administration findings |
| E87 | Nurse | Named in medication administration findings |
| E88 | Nurse | Named in medication administration findings |
| E89 | Nurse | Named in medication administration findings |
| E90 | Nurse | Named in medication administration findings |
| E91 | Nurse | Named in medication administration findings |
| E92 | Nurse | Named in medication administration findings |
| E93 | Nurse | Named in medication administration findings |
| E94 | Nurse | Named in medication administration findings |
| E95 | Nurse | Named in medication administration findings |
| E96 | Nurse | Named in medication administration findings |
| E97 | Nurse | Named in medication administration findings |
| E98 | Nurse | Named in medication administration findings |
| E99 | Nurse | Named in medication administration findings |
| E100 | Nurse | Named in medication administration findings |
Inspection Report
Annual Inspection
Deficiencies: 8
Mar 26, 2025
Visit Reason
The inspection was conducted as an annual survey of Kutz Rehabilitation and Nursing facility to assess compliance with federal regulations and standards.
Findings
The survey identified multiple deficiencies including medication administration errors, failure to notify dialysis center about medication availability, improper labeling and storage of drugs, incomplete resident records, inadequate infection prevention and control practices, and deficiencies in the antibiotic stewardship program and resident call system. The facility was cited for failure to maintain accurate medical records, ensure proper medication management, and implement effective quality assurance and performance improvement activities.
Severity Breakdown
SS=D: 5
SS=E: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to notify dialysis center that resident was not receiving ordered medication Sevelamer prior to 3/24/25. | — |
| Medication administration errors including missed doses of Dovato and Formoterol. | — |
| Failure to label and store drugs and biologicals properly, including insulin pens without open date labels. | SS=D |
| Resident records lacked complete and accurate information, including fall risk assessments and medical documentation. | SS=D |
| Failure to establish and implement effective quality assurance and performance improvement (QAPI) program addressing medication errors and resident abuse. | SS=E |
| Infection prevention and control program deficiencies including failure to maintain Enhanced Barrier Precautions and implement antibiotic stewardship program. | SS=D |
| Failure to ensure residents had functioning call bell systems. | SS=D |
| Failure to maintain effective training program for new nursing staff on IV medication administration. | SS=E |
Report Facts
Missed medication doses: 32
Residents reviewed: 35
Medication errors: 2
Audit frequency: 3
Date of survey: Mar 26, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E9 | Registered Nurse (RN) | Confirmed missing doses of medication and labeling issues during interviews. |
| E8 | Licensed Practical Nurse (LPN) | Documented medication administration and labeling issues. |
| E1 | Chief Executive Officer / Licensed Nursing Home Administrator (CEO/LNHA) | Participated in exit conference and interviews regarding findings. |
| E2 | Director of Nursing (DON) | Participated in exit conference and interviews regarding findings. |
| E3 | Staff Development/Infection Control Professional (SD/ICP) | Participated in exit conference and interviews regarding findings. |
| E11 | Contracted Medical Doctor (MD) | Made aware of medication issues and ordered treatments. |
| E51 | Licensed Practical Nurse (LPN) | Documented resident symptoms and clinical notes. |
| E13 | Certified Nursing Assistant (CNA) | Reported on call bell issues during interview. |
| E14 | Licensed Nurse | Interviewed regarding IV medication administration training. |
| E15 | Licensed Practical Nurse (LPN) | Interviewed regarding resident catheter care. |
| E30 | RN Supervisor | Documented resident progress notes. |
Inspection Report
Follow-Up
Census: 79
Deficiencies: 0
May 14, 2024
Visit Reason
An unannounced Follow-Up and Complaint Survey to the Annual and Complaint Survey ending February 16, 2024, was conducted from May 9, 2024 through May 14, 2024 at the facility.
Findings
No deficiencies were identified at the time of the survey. The facility was found to be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities as of April 15, 2024.
Complaint Details
The visit was complaint-related as it was a Follow-Up and Complaint Survey, but no deficiencies were found and the facility was in substantial compliance.
Report Facts
Survey sample size: 20
Inspection Report
Recertification Complaint Survey
Census: 82
Deficiencies: 12
Feb 16, 2024
Visit Reason
A Recertification and Complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of the Delaware Department of Health and Social Services, Division of Health Care Quality from 02/12/24 to 02/16/24.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified related to resident and family group participation, notification of changes, grievances, abuse and neglect, care planning, skin integrity, food safety, and other regulatory requirements.
Complaint Details
The survey included complaint investigations related to resident grievances, abuse, neglect, failure to notify physicians, failure to provide care, and other concerns. Some allegations were substantiated, including neglect and failure to report incidents timely.
Severity Breakdown
F565: 1
F580: 1
F585: 1
F600: 1
F609: 1
F623: 1
F625: 1
F657: 1
F686: 1
F689: 1
F690: 1
F812: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to provide feedback and/or resolutions to resident complaints and grievances discussed in monthly resident council meetings. | F565 |
| Failure to ensure physicians were notified of changes in residents' conditions, including refusal to wear splints. | F580 |
| Failure to resolve grievances timely and thoroughly, including lack of documentation and investigation. | F585 |
| Failure to protect residents from abuse, neglect, and exploitation, including failure to report incidents timely. | F600 |
| Failure to ensure staff reported and investigated allegations of abuse and neglect timely and thoroughly. | F609 |
| Failure to provide timely notification of resident transfers and discharges. | F623 |
| Failure to provide timely notice of bed hold policy and return requirements. | F625 |
| Failure to develop and revise comprehensive care plans timely and accurately. | F657 |
| Failure to prevent pressure ulcers and provide appropriate treatment. | F686 |
| Failure to ensure safe environment free from accident hazards. | F689 |
| Failure to investigate and prevent urinary and bowel incontinence appropriately. | F690 |
| Failure to maintain sanitary kitchen conditions and food safety standards. | F812 |
Report Facts
Survey Census: 82
Sample Size: 25
Supplemental Residents: 4
Deficiencies cited: 12
Fall incidents: 1
Grievances reviewed: 9
Grievances unresolved: 9
Audit frequency: 3
Corrective action completion date: Apr 15, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Barbara Martin | Licensed Practical Nurse (LPN) | Named in care plan update for Resident #8. |
| Dr. Dattani | Notified about resident R11's refusal to wear splint. | |
| Social Services Director (SSD) | Social Services Director | Investigated grievances and interviewed residents and staff. |
| Administrator | Administrator | Oversaw grievance investigations and corrective actions. |
| Director of Nursing (DON) | Director of Nursing | Involved in grievance and abuse investigations and audits. |
| Staff Developer | Educates staff on grievance and abuse policies. | |
| Certified Nursing Assistant (CNA) 1 | Certified Nursing Assistant | Involved in neglect and abandonment allegations. |
| Certified Nursing Assistant (CNA) 4 | Certified Nursing Assistant | Involved in resident care and fall incident. |
| Licensed Practical Nurse (LPN) 2 | Licensed Practical Nurse | Assessed resident's sacral wound. |
| Registered Nurse (RN) 1 | Registered Nurse | Involved in resident care and incident reporting. |
| Registered Nurse (RN) 4 | Registered Nurse | Involved in wound care documentation. |
| Staff Development Coordinator (SDC) | Staff Development Coordinator | Audited falls and staff training. |
| Food Service Director | Food Service Director | Responsible for kitchen audits and food safety. |
| Dietary Manager (DM) | Dietary Manager | Observed kitchen and food service conditions. |
Inspection Report
Annual Inspection
Census: 68
Deficiencies: 14
Jan 9, 2023
Visit Reason
An unannounced Annual and Complaint Survey was conducted at the facility beginning January 3, 2023 and ending January 9, 2023 to assess compliance with applicable regulations.
Findings
The survey identified deficiencies related to dementia training, incident reporting, resident rights, care planning, medication management, infection control, and other regulatory requirements. The facility failed to ensure required dementia training for staff, timely reporting of incidents, and proper documentation and care for residents in several areas.
Deficiencies (14)
| Description |
|---|
| Facility failed to ensure required dementia training was completed for three out of nine randomly sampled staff members. |
| Facility failed to inform the State Agency of a resident's fall with injury resulting in transfer to an acute care facility within required timeframes. |
| Facility failed to ensure resident rights were protected, including dignity and privacy during medication administration. |
| Facility failed to ensure consistent, accurate, and up-to-date advanced directives and code status documentation for residents. |
| Facility failed to notify residents or representatives of changes in a timely manner and failed to provide required beneficiary notices. |
| Facility failed to provide adequate grievance process and timely resolution of grievances. |
| Facility failed to develop and implement baseline care plans within required timeframes for residents. |
| Facility failed to ensure prompt emergency transportation for a resident with low oxygen levels and facial drooping. |
| Facility failed to conduct monthly drug regimen reviews and act on pharmacist recommendations for medication irregularities. |
| Facility failed to ensure psychotropic drug orders were limited and monitored according to regulations. |
| Facility failed to maintain adequate infection prevention and control program and antibiotic stewardship. |
| Facility failed to routinely monitor food temperatures and maintain food safety standards. |
| Facility failed to submit required staffing information based on payroll data in a timely manner. |
| Facility failed to maintain effective quality assessment and performance improvement program. |
Report Facts
Facility census: 68
Investigative sample size: 35
Staff dementia training deficiency count: 3
Resident falls reviewed: 3
Residents reviewed for dignity: 3
Residents reviewed for advanced directives: 24
Residents reviewed for beneficiary notice: 3
Residents reviewed for grievances: 2
Residents reviewed for baseline care plans: 2
Residents reviewed for emergency transportation: 1
Residents reviewed for drug regimen: 5
Residents reviewed for psychotropic drug orders: 5
Meals served without recorded temperatures: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator (NHA) | Interviewed regarding dementia training and incident reporting findings |
| E2 | Director of Nursing (DON) | Interviewed and participated in exit conference regarding findings |
| E3 | Assistant Director of Nursing (ADON) | Participated in exit conference and interviews |
| E4 | Administrator in Training (AIT) | Participated in exit conference and interviews |
| E8 | Licensed Practical Nurse (LPN) | Interviewed regarding privacy and dignity deficiencies |
| E11 | Staff member | Interviewed regarding incident reporting and fall notification |
| E12 | Registered Nurse (RN) | Interviewed regarding medication administration and psychotropic drug monitoring |
| E21 | Registered Nurse (RN) | Interviewed regarding emergency transportation and clinical documentation |
| E23 | Certified Nurse Aide (CNA) | Interviewed regarding urinary bag privacy |
| C1 | Pharmacy Consultant | Interviewed regarding medication regimen reviews |
| FM1 | Family Member | Interviewed regarding grievance process and resident concerns |
Inspection Report
Follow-Up
Census: 65
Deficiencies: 0
Sep 7, 2022
Visit Reason
An unannounced Follow-up Survey to the Complaint Survey ending July 1, 2022, was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection on September 7, 2022.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care as of August 29, 2022. No deficiencies were identified at the time of the survey.
Report Facts
Sample size: 3
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Jul 1, 2022
Visit Reason
An unannounced complaint and extended survey was conducted at the facility from June 27, 2022 through July 1, 2022 to investigate a complaint regarding delayed CPR response and code status issues.
Findings
The facility delayed providing CPR to a resident upon finding the resident unresponsive, resulting in an approximate 45 minute delay. Nursing staff failed to locate the resident's accurate code status in the electronic health record and failed to initiate timely emergency response. Multiple corrective actions and education were implemented to address these issues.
Complaint Details
The complaint investigation found that the facility delayed CPR for resident R1 for approximately 45 minutes due to failure to locate accurate code status and failure to initiate a Code Blue. The complaint was substantiated and corrective actions were implemented.
Deficiencies (1)
| Description |
|---|
| Personnel failed to provide basic life support, including CPR, to a resident requiring emergency care prior to arrival of emergency medical personnel, resulting in delayed CPR initiation. |
Report Facts
Residents reviewed for death: 5
Delay in CPR initiation: 45
Facility census: 62
911 calls: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E4 | RN Supervisor | Named in findings related to failure to locate code status and delayed emergency response. |
| E5 | LPN | Assigned nurse to resident R1, involved in emergency response and education. |
| E2 | Director of Nursing (DON) | Initiated facility-wide education and training related to code status and CPR policy. |
| E1 | Nursing Home Administrator (NHA) | Notified of Immediate Jeopardy during the meeting. |
| E3 | Assistant Director of Nursing (ADON) | Notified of Immediate Jeopardy during the meeting. |
Inspection Report
Abbreviated Survey
Census: 56
Deficiencies: 1
Jan 20, 2021
Visit Reason
An unannounced 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, beginning January 20, 2021 and ending January 22, 2021.
Findings
The facility failed to ensure residents were seated at least six feet apart during communal dining, which was corrected by repositioning furniture, placing partitions, and establishing guidelines for social distancing. Corrective actions were implemented immediately and monitoring plans were established to ensure ongoing compliance.
Deficiencies (1)
| Description |
|---|
| Failure to place residents 6 feet apart for social distancing during meal time in communal dining areas. |
Report Facts
Facility census: 56
Survey sample: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E5 | Certified Nurse's Aide (CNA) | Observed seated less than six feet apart during communal dining |
| E6 | Licensed Practical Nurse (LPN) | Observed seated less than six feet apart during communal dining |
| E4 | Registered Nurse Supervisor (RN-Supervisor) | Confirmed residents were seated less than six feet apart and repositioned residents |
| E1 | Executive Director (ED) | Observed bringing plastic partitions to place between residents during dining |
| E2 | Director of Nursing (DON) | Observed bringing plastic partitions to place between residents during dining |
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