Inspection Report Summary
The most recent inspection on December 23, 2025, found the facility to be in substantial compliance with no deficiencies noted. Prior inspections showed a pattern of multiple deficiencies related mainly to resident care planning, activities of daily living assistance, respiratory and continence care, food safety, and recordkeeping. Several complaint investigations substantiated issues including failure to prevent and investigate abuse, inadequate pressure ulcer care, medication management errors leading to an Immediate Jeopardy finding, and staffing shortages. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s compliance appears to have improved over time, with the most recent follow-up confirming substantial compliance after earlier periods of cited deficiencies.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
15.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
76% worse than Delaware average
Delaware average: 8.8 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
88 residents
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 23, 2025
Visit Reason
A desk review follow-up was conducted on December 23, 2025, of the Annual and Complaint survey ending September 23, 2025, which was delayed due to government shutdown.
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 December 5, 2025.
Report Facts
Survey end date: Sep 23, 2025
Inspection Report
Annual Inspection
Census: 88
Deficiencies: 8
Date: Sep 23, 2025
Visit Reason
An unannounced Annual, Complaint and Emergency Preparedness survey was conducted at the facility from September 15, 2025 through September 23, 2025 to assess compliance with federal and state regulations for skilled and intermediate care nursing facilities.
Findings
The survey identified multiple deficiencies based on observations, interviews, and clinical record reviews. Deficiencies involved comprehensive care planning, ADL care, respiratory care, bowel/bladder incontinence management, dental services, food safety, and resident records. Corrective actions and education plans were outlined for each deficiency.
Deficiencies (8)
Failure to develop and implement a comprehensive person-centered care plan addressing oxygen administration via nasal cannula and use of an incentive spirometer.
Failure to provide adequate ADL care including nail care and dependent resident care.
Failure to increase/prevent decrease in range of motion/mobility for a resident with limited mobility.
Failure to provide bowel/bladder incontinence care and individualized toileting program.
Failure to provide adequate respiratory/tracheostomy care and suctioning including proper storage and cleaning of equipment.
Failure to provide routine and emergency dental services to residents.
Failure to ensure food procurement, storage, preparation, and serving met sanitary requirements.
Failure to maintain resident records as complete, accurate, accessible, and confidential.
Report Facts
Residents present: 88
Survey sample size: 30
Deficiency completion dates: Dec 5, 2025
Inspection Report
Follow-Up
Census: 90
Deficiencies: 1
Date: Jan 28, 2025
Visit Reason
An unannounced Follow-up Survey to the Annual, Complaint and Emergency Preparedness Survey ending November 25, 2024, was conducted by the State of Delaware Division of Health Care Quality from January 24, 2025 through January 28, 2025.
Complaint Details
This was a follow-up survey to the Annual, Complaint and Emergency Preparedness Survey ending November 25, 2024.
Findings
The facility was found not to be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care as of December 5, 2024. Deficiencies related to bowel/bladder incontinence, catheter, and urinary tract infections were identified, including failure to assess and implement measures to restore/maintain continence for one resident.
Deficiencies (1)
Failure to assess resident's continence and implement measures to restore/maintain continence for one resident with urinary and fecal incontinence.
Report Facts
Facility census: 90
Survey sample size: 27
Dates of survey: January 24, 2025 through January 28, 2025
Completion date for plan of correction: February 11, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Director of Nursing (DON) | Interviewed regarding resident's bladder assessment and continence status |
| E1 | Nursing Home Administrator (NHA) | Present during exit conference reviewing findings |
| E3 | Corporate Nurse | Present during exit conference reviewing findings |
| E4 | Certified Nursing Assistant (CNA) | Interviewed regarding resident's use of urinal |
| E6 | Certified Nursing Assistant (CNA) | Interviewed regarding resident's urinal usage |
| E7 | Certified Nursing Assistant (CNA) | Interviewed regarding resident's incontinence and care |
Inspection Report
Annual Inspection
Census: 104
Deficiencies: 15
Date: Nov 25, 2024
Visit Reason
An unannounced annual and complaint survey was conducted at the facility from November 12, 2024 through November 25, 2024, including an emergency preparedness survey.
Findings
The survey identified multiple deficiencies related to incident reporting, notification of changes, grievances, reporting of alleged violations, investigation of alleged violations, coordination of PASARR and assessments, care plan timing and revision, activities of daily living care, psychotropic medication monitoring, food safety, resident records confidentiality, and pressure ulcer treatment. The facility failed to meet several regulatory requirements and has plans for correction with compliance dates mostly set for January 9, 2025.
Deficiencies (15)
Failure to thoroughly investigate and document incident reports related to resident falls.
Failure to notify provider of resident refusing dialysis services.
Failure to properly handle grievances including timely follow-up and documentation.
Failure to report alleged violations timely to appropriate authorities.
Failure to investigate allegations of abuse and neglect thoroughly.
Failure to coordinate PASARR assessments and referrals timely.
Failure to conduct timely care plan meetings and revise care plans as needed.
Failure to provide adequate care for activities of daily living for dependent residents.
Failure to monitor side effects of psychotropic medications and provide education.
Failure to provide adequate treatment and monitoring for pressure ulcers.
Failure to provide adequate nutrition and hydration to residents.
Failure to provide adequate continence care and toileting assistance.
Failure to provide timely and adequate dental services.
Failure to ensure food was stored, prepared, and served safely to residents.
Failure to maintain resident records confidential and properly documented.
Report Facts
Facility census: 104
Survey sample size: 46
Compliance date: Jan 9, 2025
Residents reviewed for falls: 2
Residents reviewed for dialysis refusal: 2
Residents reviewed for grievances: 1
Residents reviewed for abuse allegations: 1
Residents reviewed for PASARR: 2
Residents reviewed for care plan timing: 31
Residents reviewed for ADL care: 12
Residents reviewed for psychotropic meds: 5
Residents reviewed for pressure ulcers: 4
Residents reviewed for nutrition/hydration: 3
Residents reviewed for continence: 5
Residents reviewed for dental services: 3
Residents reviewed for food safety: Food safety deficiencies noted but no specific resident count
Residents reviewed for resident records: 1
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 4
Date: May 22, 2024
Visit Reason
An unannounced complaint survey was conducted at the facility from May 16, 2024 through May 22, 2024 based on observations, interviews, and review of clinical records and other documentation.
Complaint Details
The complaint investigation was substantiated as the facility failed to implement the grievance process for pressure ulcers and had deficiencies in assessment, discharge planning, and pressure ulcer care.
Findings
The facility was found deficient in multiple areas including failure to implement the grievance process for pressure ulcers, inaccurate completion of admission assessments, inadequate discharge planning, and failure to ensure proper monitoring and treatment of pressure ulcers. Root cause analyses and corrective actions were planned for each deficiency.
Deficiencies (4)
Failure to implement the grievance process for pressure ulcers.
Failure to accurately complete the admission MDS assessment.
Failure to develop and implement an effective discharge planning process.
Failure to ensure monitoring and treatment of pressure ulcers including skin checks and wound care.
Report Facts
Facility census: 112
Sample size: 7
Deficiency completion dates: Jun 25, 2024
Inspection Report
Follow-Up
Census: 115
Deficiencies: 2
Date: Apr 22, 2024
Visit Reason
An unannounced follow-up and complaint survey was conducted from April 18 through April 22, 2024, to assess correction of previous deficiencies and investigate complaint allegations.
Complaint Details
The visit was triggered by a complaint survey ending February 27, 2024, and included investigation of allegations related to resident care and documentation accuracy. The complaint was substantiated as deficiencies were found.
Findings
The survey found deficiencies related to accuracy of assessments and provision of ADL care to dependent residents. Corrective actions including re-education and audits were planned. No further errors were noted in MDS documentation after correction.
Deficiencies (2)
Failure to ensure accuracy of Minimum Data Set (MDS) assessments for resident falls.
Failure to ensure Activities of Daily Living (ADL) care was provided to dependent residents, including those with indwelling catheters.
Report Facts
Facility census: 115
Survey sample size: 18
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E17 | MDS Coordinator | Interviewed regarding MDS documentation and confirmed errors |
| E15 | Certified Nursing Assistant (CNA) | Documented resident care deficiencies and was on administrative leave pending investigation |
| E18 | Unlicensed Medication Personnel (UM) | Involved in resident care and audit findings |
| E2 | Director of Nursing (DON) | Confirmed care deficiencies and participated in exit conference |
| E16 | Regional Nurse Consultant | Participated in exit conference |
| E1 | Nursing Home Administrator (NHA) | Participated in exit conference and findings review |
Inspection Report
Complaint Investigation
Census: 125
Deficiencies: 12
Date: Feb 27, 2024
Visit Reason
An unannounced Complaint and Extended survey was conducted from February 22, 2024 through February 27, 2024 to investigate complaints and assess compliance with regulatory requirements.
Complaint Details
The survey was complaint-driven and included an extended review based on allegations. Immediate Jeopardy was identified related to medication errors affecting a resident's health.
Findings
The survey identified multiple deficiencies related to residents' rights, nutrition and hydration, physician visits, medication administration, staff training, communication, resident rights, abuse prevention, quality assurance, infection control, and compliance and ethics training. The facility failed to meet several regulatory requirements, including failure to offer advance directives, monitor hydration status, ensure accurate insulin administration, and provide mandatory staff training.
Deficiencies (12)
Failure to offer residents the opportunity to formulate an Advance Directive.
Failure to ensure a resident at risk for dehydration was monitored and provided adequate hydration.
Failure to ensure physician orders for insulin were accurately reviewed and documented.
Failure to complete performance reviews for nursing aides annually.
Failure to ensure residents are free of significant medication errors, resulting in an Immediate Jeopardy situation.
Failure to provide effective communication training for direct care staff.
Failure to provide resident rights training for staff.
Failure to provide abuse, neglect, and exploitation training for staff.
Failure to provide Quality Assurance and Performance Improvement (QAPI) training for staff.
Failure to provide infection control training for staff.
Failure to provide compliance and ethics training for staff.
Failure to provide required in-service training for nurse aides.
Report Facts
Facility census: 125
Sample size: 3
Immediate Jeopardy call date: Feb 23, 2024
Completion date for plan of correction: Apr 4, 2024
Inspection Report
Annual Inspection
Census: 120
Deficiencies: 13
Date: Jan 5, 2024
Visit Reason
An unannounced annual, complaint, and emergency preparedness survey was conducted at Milford Center from December 12, 2023 through December 21, 2023 and January 3, 2024 through January 5, 2024 to assess compliance with state and federal regulations.
Findings
The facility was found noncompliant with multiple Delaware Code Chapters and federal regulations, including failure to maintain minimum staffing levels, inadequate emergency preparedness training, medication management errors, inadequate resident care planning, and environmental safety issues. Root cause analyses identified deficiencies in monitoring and staff education.
Deficiencies (13)
Failure to provide minimum staffing level of 3.28 hours of direct care per resident per day on two days reviewed.
Failure to ensure staff received annual Emergency Preparedness training as required.
Failure to notify resident representative of medication changes and failure to conduct medication audits.
Failure to ensure resident rights to informed consent and treatment decisions.
Failure to provide adequate accommodations for residents including pull cords for overhead lights.
Failure to maintain safe, clean, and homelike environment including adequate water temperature and lighting.
Failure to ensure advance directives were obtained and honored for residents.
Failure to ensure accurate and timely completion of MDS assessments and care plans.
Failure to provide adequate supervision and care to prevent accidents and elopements.
Failure to provide adequate pain management and monitoring.
Failure to maintain proper storage, labeling, and monitoring of medications and biologicals.
Failure to provide adequate food safety and sanitation in food preparation and storage.
Failure to provide required in-service training for nurse aides.
Report Facts
Facility census: 120
Survey sample size: 32
Staffing level: 3.28
Staffing level: 3.22
Staffing level: 2.68
Deficiencies cited: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Allen | Nursing Home Administrator | Named in relation to staffing and emergency preparedness findings |
| E1 | Nursing Home Administrator | Reviewed staffing worksheets and participated in findings review |
| E8 | Certified Nursing Assistant | Received Emergency Preparedness training and involved in care findings |
| E9 | Certified Nursing Assistant | Received Emergency Preparedness training and involved in care findings |
| E10 | Certified Nursing Assistant | Received Emergency Preparedness training and involved in care findings |
| E11 | Certified Nursing Assistant | Involved in CNA evaluations and training findings |
| E21 | Certified Nursing Assistant | Interviewed regarding resident care and environmental findings |
| E24 | Unit Manager | Interviewed regarding resident assessments and medication storage |
| E31 | Licensed Practical Nurse | Interviewed regarding resident safety and elopement device checks |
| E32 | Licensed Practical Nurse | Interviewed regarding resident care and medication management |
| E33 | Psychiatric Nurse Practitioner | Interviewed regarding medication changes and resident care |
| E58 | Nurse Practice Educator | Responsible for monitoring emergency preparedness training compliance |
| E65 | Dietary Manager | Interviewed regarding food safety and sanitation findings |
| E70 | Maintenance Director | Interviewed regarding environmental safety and lighting issues |
| E85 | Director of Nursing | Conducted audits and involved in multiple findings and corrective actions |
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 3
Date: Aug 30, 2023
Visit Reason
An unannounced complaint survey was conducted at the facility on August 30, 2023, triggered by concerns related to staffing levels and food safety.
Complaint Details
The survey was complaint-driven and substantiation status is not explicitly stated in the report.
Findings
The facility failed to maintain the minimum required staffing level of 3.28 hours of direct care per resident per day for six days out of 21 days reviewed. Additionally, food safety violations were found including mold in the walk-in refrigerator and improper sealing of seams allowing pest access.
Deficiencies (3)
Failure to maintain minimum staffing level of 3.28 hours of direct care per resident per day.
Occurrence of mold in high moisture areas and failure to maintain food storage areas in a clean and safe condition.
Seams in the metal floor of the walk-in refrigerator were not sealed, allowing pest access and debris accumulation.
Report Facts
Facility census: 117
Staffing hours per resident per day: 3.28
Days out of compliance: 6
PPD values: Daily direct care hours per resident ranged from 2.94 to 3.24 on specific dates listed
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Corporate | Participated in exit conference reviewing findings |
| E2 | Senior Market Director of Nursing | Participated in exit conference reviewing findings |
| E3 | Director of Nursing | Participated in exit conference reviewing findings |
Inspection Report
Complaint Investigation
Census: 123
Deficiencies: 3
Date: Apr 26, 2023
Visit Reason
An unannounced Complaint Survey was conducted from April 21, 2023 through April 26, 2023 based on allegations of abuse and failure to protect residents.
Complaint Details
The complaint investigation found substantiated allegations of failure to report and investigate resident to resident abuse, failure to protect residents, and failure to ensure proper QAPI meeting attendance.
Findings
The facility failed to report and investigate allegations of resident to resident abuse in a timely and thorough manner, failed to protect residents from abuse, and failed to ensure attendance of required members at Quality Assurance Performance Improvement (QAPI) meetings. The facility was unable to correct these deficiencies at the time of the survey.
Deficiencies (3)
Failure to report and investigate allegations of resident to resident abuse within required timeframes.
Failure to protect residents from abuse and prevent further potential abuse.
Failure to ensure attendance of required members at Quality Assurance Performance Improvement (QAPI) meetings.
Report Facts
Facility census: 123
Investigative sample size: 14
Timeframe of survey: 6
Completion date for corrections: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patrick Baker | LNHA | Provider's signature on the state survey report |
| E12 | Dementia Program Director | Interviewed regarding resident to resident abuse and investigation |
| E1 | NHA | Interviewed and participated in exit conference |
| E2 | ADON | Interviewed and participated in exit conference |
| E4 | SA | Interviewed during exit conference |
Inspection Report
Follow-Up
Census: 113
Deficiencies: 0
Date: Aug 24, 2022
Visit Reason
An unannounced follow-up survey to the Annual and Complaint Survey ending June 28, 2022, was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection on August 23 through August 24, 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 10, 2022. No deficiencies were identified at the time of the survey.
Report Facts
Survey sample size: 20
Inspection Report
Annual Inspection
Census: 121
Deficiencies: 13
Date: Jun 28, 2022
Visit Reason
An unannounced Annual, Complaint and Extended Survey was conducted at the Milford Center from June 7, 2022 through June 28, 2022 to assess compliance with applicable federal and state regulations.
Findings
The facility was found to have multiple deficiencies including failure to meet minimum staffing levels, failure to provide emergency preparedness training to staff, failure to protect residents from verbal abuse, failure to ensure accurate assessments and care plans, failure to prevent and treat pressure ulcers, failure to ensure proper infection control and COVID-19 testing, and failure to ensure proper food safety and medication management. Corrective actions and plans of correction were documented for each deficiency.
Deficiencies (13)
Failure to provide emergency preparedness training to staff as required by regulations.
Failure to protect resident R29 from verbal abuse by staff.
Failure to implement abuse/neglect policies and procedures to prevent further abuse.
Failure to report alleged abuse within required timeframes.
Failure to ensure accurate and timely assessments and care plans for residents.
Failure to provide appropriate care and treatment for pressure ulcers.
Failure to ensure proper infection prevention and control program including hand hygiene and COVID-19 testing.
Failure to ensure proper food procurement, storage, preparation, and sanitation.
Failure to provide adequate supervision to prevent accidents.
Failure to provide adequate training and competency validation for emergency tracheostomy care.
Failure to provide adequate pain management and documentation.
Failure to provide adequate monitoring and documentation of psychotropic medication use.
Failure to provide adequate hand hygiene and personal protective equipment (PPE) use.
Report Facts
Facility census: 121
Survey dates: June 7, 2022 through June 28, 2022
Staffing hours per patient day: 3.28
Staffing hours per patient day: 3.2
Staffing hours per patient day: 3.16
Staffing hours per patient day: 3.22
Deficiency completion dates: Most corrective actions planned for completion by 8/10/22
Residents sampled for abuse: 3
Residents reviewed for pain management: 3
Residents reviewed for psychotropic medication monitoring: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E40 | Certified Nurse's Aide | Named in emergency preparedness training deficiency and abuse/neglect training |
| E41 | Certified Nurse's Aide | Named in emergency preparedness training deficiency |
| E46 | Agency Contract Registered Nurse | Named in verbal abuse allegation and abuse policy deficiencies |
| R29 | Resident | Subject of verbal abuse allegations |
| E2 | Director of Nursing | Interviewed regarding staffing and abuse allegations |
| E5 | Registered Nurse Manager | Interviewed regarding care plans and assessments |
| E23 | Director of Recreation | Interviewed regarding activity program |
| E35 | Licensed Practical Nurse | Interviewed regarding code status documentation |
| E24 | Registered Nurse Wound Care Nurse | Interviewed regarding wound care and pressure ulcers |
| R87 | Resident | Subject of care plan and pain management deficiencies |
| E12 | Nurse Practice Educator | Interviewed regarding tracheostomy care and pain management |
| E1 | Nursing Home Administrator | Interviewed regarding multiple deficiencies and corrective actions |
| E43 | Medical Doctor | Physician providing orders and evaluations |
| R75 | Resident | Subject of pressure ulcer and care plan deficiencies |
| E30 | Cook | Interviewed regarding food safety deficiencies |
| E38 | Certified Nurse's Aide | Interviewed regarding food safety deficiencies |
| E50 | Supervisor | Interviewed regarding respiratory contract service |
| E6 | Registered Nurse Unit Manager | Interviewed regarding resident code status |
| E87 | Resident | Subject of pain management deficiency |
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 2
Date: Aug 11, 2021
Visit Reason
An unannounced complaint survey was conducted at the facility from August 6, 2021 through August 11, 2021 to investigate complaints and assess compliance with regulatory requirements.
Complaint Details
The visit was complaint-related and unannounced, conducted over several days. The deficiencies cited were based on observations, interviews, and record reviews. The complaint was substantiated as evidenced by the findings.
Findings
The facility failed to ensure dignity during dining for one resident, and failed to ensure timely and comprehensive care plan development and interdisciplinary team participation for sampled residents. Deficiencies were identified related to resident rights and care plan timing and revision.
Deficiencies (2)
Failure to ensure care was provided in a way that promoted dignity during dining for one resident who was fed milk directly from a carton without a drinking cup or glass.
Failure to develop comprehensive care plans within 7 days after assessment and failure to ensure interdisciplinary team participation in care plan review for sampled residents.
Report Facts
Residents present: 109
Survey sample size: 8
Dates of survey: August 6, 2021 through August 11, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E4 | Certified Nurse's Aide (CNA) | Observed feeding resident R4 and interviewed regarding feeding practices |
| E5 | Registered Nurse (RN), Unit Manager (UM) | Confirmed feeding practice and participated in interviews |
| 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 |
| E3 | Corporate Nurse | Participated in exit conference and review of findings |
| E7 | Social Worker (SW) | Interviewed regarding care plan input |
| E9 | Certified Nurse's Aide (CNA) | Interviewed regarding care plan input |
| E10 | Certified Nurse's Aide (CNA) | Interviewed regarding care plan input |
| E11 | Certified Nurse's Aide (CNA) | Interviewed regarding care plan input |
| E8 | Staff Registered Nurse (RN) | Interviewed regarding interdisciplinary communication |
Inspection Report
Follow-Up
Census: 104
Deficiencies: 0
Date: Apr 5, 2021
Visit Reason
An unannounced follow-up survey was conducted on April 5, 2021, by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection, following a complaint survey ending February 24, 2021.
Complaint Details
The visit was a follow-up to a complaint survey ending February 24, 2021. No deficiencies were found, indicating compliance.
Findings
The facility was found to be in compliance with 42 CFR, Part 483, Subpart B, Requirements for Long Term Care. No deficiencies were identified at the time of the survey.
Report Facts
Survey sample size: 5
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 1
Date: Feb 24, 2021
Visit Reason
An unannounced Complaint Survey was conducted at the facility from February 17, 2021 through February 24, 2021 to investigate complaints and assess compliance with regulatory requirements.
Complaint Details
The complaint investigation was substantiated based on record review and interviews showing that a resident (R2) was transferred twice without a mechanical lift and without adequate supervision, resulting in a broken leg and pain. The facility failed to complete lift/transfer assessments and did not follow safe resident handling policies.
Findings
The facility failed to ensure that appropriate assistive devices and supervision were used during resident transfers, resulting in harm to a resident who experienced pain and a broken leg. The facility lacked evidence of completed lift/transfer assessments prior to transfers and failed to provide adequate supervision and mechanical lift use.
Deficiencies (1)
Failure to ensure that the resident environment remains free of accident hazards and that each resident receives adequate supervision and assistance devices to prevent accidents, resulting in harm to a resident during transfers.
Report Facts
Survey sample size: 3
Facility census: 106
Deficiency tag: 689
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator (NHA) | Participated in exit conference reviewing findings |
| E2 | Director of Nursing (DON) | Participated in exit conference reviewing findings |
| E3 | Assistant Director of Nursing (ADON) | Participated in exit conference reviewing findings and involved in staff education |
| E4 | Certified Nurse's Aide (CNA) | Interviewed regarding resident transfers and supervision |
| E5 | Licensed Practical Nurse (LPN) | Interviewed regarding lift/transfer assessments and resident status |
Inspection Report
Routine
Census: 110
Deficiencies: 0
Date: Jan 5, 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 from December 31, 2020 through January 5, 2021.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19. No deficiencies were identified at the time of the survey.
Report Facts
Facility census: 110
Inspection Report
Routine
Census: 90
Deficiencies: 0
Date: Oct 22, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection on October 22, 2020.
Findings
The facility was found to be in compliance with 42 CFR §483.80 and has implemented the CMS and CDC recommended practices to prepare for COVID-19. No deficiencies were identified at the time of the survey.
Report Facts
Facility census: 90
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 3
Date: Jun 2, 2020
Visit Reason
An unannounced complaint survey was conducted at the facility from May 26, 2020 through June 2, 2020 based on interviews, review of resident clinical records, and other facility documentation.
Complaint Details
The complaint investigation was substantiated based on findings that the facility failed to develop care plans for dialysis residents, failed to communicate COVID-19 status to dialysis centers and transportation, and failed to implement adequate infection control policies.
Findings
The facility was found deficient in developing and implementing comprehensive care plans for dialysis residents and in ensuring dialysis care and communication of COVID-19 status to dialysis centers and transportation services. Infection prevention and control practices were also found inadequate, particularly in communication of infectious disease status to contracted agencies.
Deficiencies (3)
Failure to develop a comprehensive care plan for one resident requiring dialysis.
Failure to provide dialysis care and services to meet the needs of two residents and failure to communicate COVID-19 status to dialysis centers and transportation.
Failure to establish and maintain an infection prevention and control program including communication of infectious disease status to contracted agencies.
Report Facts
Survey sample size: 8
Census: 83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Director of Nursing | Confirmed facility did not have care plans for dialysis residents and lacked process to communicate infectious diseases |
| E1 | Nursing Home Administrator | Participated in exit conference reviewing findings |
| E3 | Corporate Consultant | Participated in exit conference reviewing findings |
| E4 | Licensed Practical Nurse | Interviewed regarding communication of COVID-19 status to dialysis center |
| E6 | Registered Nurse | Interviewed regarding failure to follow doctor's orders to notify dialysis center of COVID-19 status |
| D1 | Dialysis Staff | Interviewed about resident dialysis visits and communication |
| D2 | Dialysis Staff | Interviewed about resident dialysis visits and communication |
| D3 | Dialysis Staff | Interviewed about communication of resident COVID-19 status |
| T1 | Transportation Staff | Interviewed about transportation of resident without notification of COVID-19 status |
| T2 | Transportation Staff | Interviewed about transportation of resident without notification of COVID-19 status |
Inspection Report
Follow-Up
Census: 68
Deficiencies: 0
Date: Jun 1, 2020
Visit Reason
An unannounced follow-up COVID-19 Focused Infection Control Survey was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection on June 1, 2020.
Findings
The facility was found to have regained substantial compliance with 42 CFR §483.80 infection control regulations and had implemented the CMS and CDC recommended practices for COVID-19. No deficiencies were identified at the time of the survey.
Report Facts
Residents present: 68
Residents with COVID-19: 41
Dialysis residents on quarantine: 2
Residents with symptoms suspected for COVID-19: 2
Asymptomatic residents: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather O. Thullett | LNHA | Provider's signature on the report |
Inspection Report
Abbreviated Survey
Census: 93
Deficiencies: 1
Date: Apr 22, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection from April 17, 2020 through April 22, 2020 to assess compliance with infection control regulations.
Findings
The facility was found to not be in compliance with 42 CFR §483.80 related to infection control. The survey identified failures in isolating and cohorting COVID-19 positive and presumptive positive residents, improper use of personal protective equipment (PPE), and inadequate infection prevention and control practices, placing residents at risk for contracting COVID-19.
Deficiencies (1)
Failure to establish and maintain an infection prevention and control program to prevent the development and transmission of communicable diseases and infections.
Report Facts
Facility census: 93
Survey sample size: 23
Date survey completed: Apr 22, 2020
Date survey started: Apr 17, 2020
Date of deficiency correction: May 19, 2020
Number of asymptomatic residents sharing rooms with COVID-19 positive residents: 12
Number of residents identified as presumptive positive COVID-19: 10
Number of residents identified as asymptomatic positive COVID-19: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator (NHA) | Notified of immediate jeopardy and provided abatement plan |
| E2 | Assistant Director of Nursing | Participated in exit teleconference reviewing findings |
| E4 | Corporate Nurse | Participated in exit teleconference reviewing findings |
| E5 | Corporate Nurse | Confirmed asymptomatic residents sharing rooms with COVID-19 positive residents |
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 6
Date: Mar 5, 2020
Visit Reason
An unannounced complaint survey was conducted at the facility from March 3, 2020 through March 5, 2020 to investigate complaints related to resident transfers, discharge requirements, bed hold policies, quality of care, competent nursing staff, and quality assurance activities.
Complaint Details
The survey was complaint triggered and substantiated as evidenced by multiple deficiencies cited related to transfer and discharge requirements, notice requirements, bed hold policy, quality of care, competent nursing staff, and quality assurance activities.
Findings
The facility failed to ensure proper documentation and communication of resident care plan goals during transfers and discharges, failed to provide timely written notices to residents or their representatives, failed to complete neurological evaluations after falls, failed to ensure nursing staff competency and training, and failed to effectively implement quality assurance and performance improvement activities.
Deficiencies (6)
Failure to ensure information was provided to the receiving provider for four residents investigated for hospitalizations, including care plan goals in transfer/discharge information.
Failure to provide written notice to residents or their representatives before transfer or discharge.
Failure to provide written notice of bed-hold policy before transfer.
Failure to complete neurological evaluations after a fall for one resident.
Failure to ensure nursing staff have competencies and skills necessary to care for residents, including training on post-transfusion assessment.
Failure of Quality Assurance and Performance Improvement (QAPI) program to correct previously cited deficiencies related to transfer and discharge requirements, notice requirements, and bed hold policy.
Report Facts
Survey sample size: 7
Residents census: 117
Dates of resident hospital transfers: Multiple dates listed for residents R1, R2, R3, and R5 hospital transfers between 2019 and 2020
Date survey completed: March 5, 2020
Plan of correction completion date: April 14, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator (NHA) | Named in findings review and interviews related to deficiencies |
| E2 | Director of Nursing (DON) | Named in findings review and interviews related to deficiencies |
| E3 | Assistant Director of Nursing (ADON) | Named in findings review and interviews related to deficiencies |
| E4 | Nurse Educator | Interviewed regarding nurse education on transfusions |
Inspection Report
Complaint Investigation
Census: 122
Deficiencies: 6
Date: Jan 16, 2020
Visit Reason
An unannounced complaint survey was conducted at the facility from January 16, 2020 through January 17, 2020 to investigate complaints related to resident care and facility compliance.
Complaint Details
The survey was complaint-driven and substantiated based on observations, interviews, and record reviews revealing multiple deficiencies in resident care and medication management.
Findings
The facility failed to ensure residents' call bells were readily accessible, failed to properly manage pain medications including documentation and administration, and failed to properly manage psychotropic and antipsychotic medications with adequate monitoring and documentation.
Deficiencies (6)
Facility failed to ensure residents' call bells were readily accessible to summon staff for assistance.
Facility failed to administer routine pain medication, document PRN pain medication on the eMAR, and ensure accuracy of pain assessment after PRN medication.
Facility failed to provide pharmaceutical services including accurate acquiring, receiving, dispensing, and administering of drugs and biologicals.
Facility failed to ensure controlled drugs were properly managed with accurate records and reconciliation.
Facility failed to ensure psychotropic drugs were used appropriately with adequate documentation and monitoring of side effects.
Facility failed to ensure antipsychotic medication use was properly indicated, monitored, and documented including AIMS testing.
Report Facts
Residents in census: 122
Survey sample size: 11
Completion dates for corrective actions: Feb 10, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator (NHA) | Named in review of findings during exit conference |
| E2 | Director of Nursing (DON) | Named in review of findings during exit conference and interviews |
| E3 | Registered Nurse (RN), Unit Manager (UM) | Interviewed regarding medication administration and resident care |
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