Inspection Reports for Regal Heights Healthcare and Rehabilitation Center
DE, 19707
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 24, 2025, found the facility in substantial compliance with no deficiencies identified. Earlier inspections showed multiple deficiencies related primarily to resident care, including medication administration, abuse prevention, infection control, and documentation, as well as facility environment and safety concerns. Complaint investigations substantiated issues such as verbal abuse, failure to report abuse timely, inadequate supervision, and care planning deficiencies. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s inspection history shows improvement, with the latest follow-up survey indicating resolution of prior cited issues.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
19.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
119% worse than Delaware average
Delaware average: 8.8 deficiencies/yearDeficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
158 residents
Based on a July 2025 inspection.
Census over time
Inspection Report
Follow-Up
Census: 158
Deficiencies: 0
Jul 24, 2025
Visit Reason
An unannounced Follow-Up and Complaint Survey was conducted at the facility from July 23, 2025, through July 24, 2025.
Findings
The facility was found to be in substantial compliance as of July 8, 2025. No deficiencies were identified at the time of the survey.
Complaint Details
The survey was complaint-related as it was a Follow-Up and Complaint Survey, but no deficiencies were found, indicating no substantiated issues.
Report Facts
Survey sample size: 30
Inspection Report
Annual Inspection
Census: 167
Deficiencies: 27
May 23, 2025
Visit Reason
An unannounced annual and complaint survey was conducted at the facility from May 14, 2025 through May 23, 2025 to assess compliance with applicable regulations and investigate complaints.
Findings
The survey identified multiple deficiencies related to facility environment, resident rights, infection control, medication administration, abuse prevention, care planning, and documentation. The facility failed to meet several regulatory requirements including safe storage of residents' valuables, accurate documentation of vaccinations, protection from verbal abuse, and proper medication error rates.
Complaint Details
The survey included complaint investigations related to missing money from a resident's purse, verbal abuse by staff, failure to report abuse allegations timely, and improper medication administration. Some complaints were substantiated as evidenced by findings.
Severity Breakdown
Severity: SS=D: 25
Deficiencies (27)
| Description | Severity |
|---|---|
| Facility failed to provide a vermin proof environment for food storage and preparation. | — |
| Facility failed to provide safe storage for residents' valuables, resulting in missing money. | — |
| Facility failed to document vaccines given to residents in Delaware's online immunization registry (DELVAX). | — |
| Deficient practice of leaving door open and not using privacy curtain while administering medications via PEG tube. | Severity: SS=D |
| Facility failed to protect resident from verbal abuse by a staff member. | Severity: SS=D |
| Facility failed to provide family with a written explanation for room/roommate change. | Severity: SS=D |
| Facility failed to report an allegation of abuse within two hours. | Severity: SS=D |
| Facility failed to ensure accuracy of residents' Minimum Data Set (MDS) assessments. | Severity: SS=D |
| Facility failed to ensure residents received proper treatment and assistive devices for hearing. | Severity: SS=D |
| Facility failed to ensure resident environment was free of accident hazards. | Severity: SS=D |
| Facility failed to ensure adequate supervision and assistance to prevent accidents. | Severity: SS=D |
| Facility failed to ensure resident received adequate assistance with eating and feeding. | Severity: SS=D |
| Facility failed to ensure medication error rates were less than 5 percent; identified 9 medication errors out of 44 opportunities. | Severity: SS=D |
| Facility failed to establish and maintain an infection prevention and control program including proper use of PPE and hand hygiene. | Severity: SS=D |
| Facility failed to ensure residents received influenza and pneumococcal immunizations or education. | Severity: SS=D |
| Facility failed to provide and document comprehensive care plans consistent with residents' needs and preferences. | Severity: SS=D |
| Facility failed to provide care and services to prevent incontinence and maintain continence. | Severity: SS=D |
| Facility failed to ensure residents with hearing deficits received proper treatment and assistive devices. | Severity: SS=D |
| Facility failed to ensure residents received treatment and devices to maintain hearing and vision. | Severity: SS=D |
| Facility failed to ensure residents received respiratory care and tracheostomy care per professional standards. | Severity: SS=D |
| Facility failed to order and implement CPAP machine settings as required. | Severity: SS=D |
| Facility failed to ensure residents received proper medication administration via feeding tubes. | Severity: SS=D |
| Facility failed to ensure residents received proper wound care and infection prevention. | Severity: SS=D |
| Facility failed to ensure residents were free from abuse, neglect, and exploitation. | Severity: SS=D |
| Facility failed to ensure residents' rights were protected including dignity, privacy, and participation in care planning. | Severity: SS=D |
| Facility failed to ensure residents received influenza vaccines and education regarding pneumococcal vaccines. | Severity: SS=D |
| Facility failed to ensure residents received COVID-19 immunizations and education. | Severity: SS=D |
Report Facts
Residents present at census: 167
Investigative sample size: 35
Medication errors: 9
Medication error rate: 20.45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Beth Ann Troy | Director of Nursing | Named in relation to findings and plan of correction signatures |
| E16 | Licensed Practical Nurse (LPN) | Named in medication administration and PPE findings |
| E1 | Nursing Home Administrator (NHA) | Named in multiple findings and exit conferences |
| E2 | Director of Nursing (DON) | Named in multiple findings and exit conferences |
| E3 | Assistant Director of Nursing (ADON) | Named in multiple findings and exit conferences |
| E47 | Maintenance Director | Named in facility environment deficiency |
| E46 | District Food Service Manager | Named in facility environment deficiency |
Inspection Report
Complaint Investigation
Census: 164
Deficiencies: 6
Feb 5, 2025
Visit Reason
An unannounced complaint survey was conducted at the facility from February 5, 2025, through February 10, 2025, based on observations, interviews, and review of clinical records and other documentation.
Findings
The facility was found deficient in multiple areas including failure to meet professional standards for post-fall assessments, inadequate supervision and assistance to prevent accidents, failure to provide respiratory care consistent with physician orders, pain management deficiencies, failure to maintain medical records confidentiality and accuracy, and unsafe patient care equipment conditions such as water temperature control.
Complaint Details
The survey was complaint-driven, conducted due to allegations related to falls, burns, respiratory care, pain management, and medical record deficiencies. The complaint was substantiated as evidenced by multiple deficiencies found.
Deficiencies (6)
| Description |
|---|
| Failure to have a registered nurse complete and document post-fall assessments for residents. |
| Failure to provide adequate supervision and assistance devices to prevent accidents, resulting in harm to a resident with burns. |
| Failure to provide respiratory care consistent with physician's orders for a resident. |
| Failure to ensure proper pain management and assessment for residents. |
| Failure to maintain resident medical records that are complete, accurate, readily accessible, and systematically organized. |
| Failure to maintain all mechanical, electrical, and patient care equipment in safe operating condition, including water temperature controls. |
Report Facts
Residents present: 164
Investigative sample: 28
Deficiency completion dates: 3
Resident burns percentage: 15
Water temperature: 152
Water temperature: 105
Water temperature: 110
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Thompson | Administrator | Signed the state survey report on February 5, 2025 |
| E9 | Corporate Risk Manager | Interviewed regarding facility incident reports and documentation |
| E1 | Nursing Home Administrator (NHA) | Interviewed and participated in exit conference |
| E2 | Director of Nursing (DON) | Interviewed and participated in exit conference; involved in staff education and audits |
| E4 | Maintenance Director | Interviewed regarding water temperature issues and corrective actions |
| E6 | Assistant Director of Nursing (ADON) | Participated in exit conference |
| E8 | Corporate IP/SP | Participated in exit conference |
| E11 | Registered Nurse (RN), charge nurse | Documented progress notes and clinical observations |
| E19 | Licensed Practical Nurse (LPN) | Documented clinical notes and interviewed regarding resident care |
| E20 | Certified Nursing Assistant (CNA) | Involved in resident care and interviewed |
| F1 | Resident's wife | Interviewed regarding resident condition and care |
| F2 | Psychiatric Nurse Practitioner (Psych NP) | Documented psychiatric periodic evaluation |
Inspection Report
Annual Inspection
Census: 168
Deficiencies: 20
May 1, 2024
Visit Reason
An unannounced annual, complaint and extended survey was conducted at the facility starting on April 18, 2024 and completed on May 1, 2024. The survey included observations, interviews, and review of clinical records and other documentation.
Findings
The survey identified multiple deficiencies related to resident rights, abuse prevention, admission policies, accuracy of assessments, care planning, communication, and safety measures. Deficiencies ranged from failure to ensure dignity and privacy to inadequate reporting of abuse and insufficient staffing.
Complaint Details
The survey included complaint investigation components. Verbal abuse was substantiated based on interviews and documentation. Other complaints related to neglect, abuse reporting, and care deficiencies were investigated with findings documented.
Severity Breakdown
Level E: 1
Deficiencies (20)
| Description | Severity |
|---|---|
| Failure to ensure residents' right to a dignified existence and privacy during meals and dressing changes. | — |
| Failure to report abuse to the State Agency within the required two-hour timeframe. | — |
| Failure to offer an advanced directive to cognitively intact residents. | — |
| Failure to ensure residents were free from abuse, neglect, and exploitation. | Level E |
| Failure to provide accurate and complete admission agreements and notices. | — |
| Failure to ensure accuracy of Minimum Data Set (MDS) assessments. | — |
| Failure to provide sufficient nursing staff to meet residents' needs. | — |
| Failure to ensure proper food safety practices including labeling and dating of food items. | — |
| Failure to ensure residents' medical records were complete and accurate. | — |
| Failure to ensure residents were free from accidents and had adequate supervision. | — |
| Failure to ensure residents received appropriate care for mobility, communication, and activities of daily living. | — |
| Failure to ensure proper management of resident elopement risks and wandering. | — |
| Failure to ensure proper handling and reporting of incidents involving resident injury and abuse. | — |
| Failure to ensure residents received timely and adequate physician visits. | — |
| Failure to ensure residents' rights related to admission, transfer, and discharge notices. | — |
| Failure to ensure residents' rights related to communication devices and privacy. | — |
| Failure to ensure proper care planning and implementation for residents' medical and psychosocial needs. | — |
| Failure to ensure residents' safety related to accident hazards and supervision. | — |
| Failure to ensure proper use and documentation of orthotic devices. | — |
| Failure to ensure proper food procurement, storage, and handling. | — |
Report Facts
Facility census: 168
Survey sample size: 58
Deficiency completion dates: 6
Residents reviewed for abuse: 5
Residents reviewed for accidents: 9
Residents reviewed for admission assessments: 6
Residents reviewed for care planning: 3
Residents reviewed for communication devices: 6
Residents reviewed for mobility: 1
Residents reviewed for medical record accuracy: 4
Residents reviewed for smoking evaluation: 4
Residents reviewed for dental care: 3
Residents reviewed for activities of daily living: 6
Residents reviewed for elopement risk: 1
Residents reviewed for accident supervision: 9
Residents reviewed for orthotic device use: 1
Residents reviewed for wound care: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E44 | Registered Nurse | Named in privacy and dressing change deficiency findings |
| R136 | Resident involved in abuse and neglect findings | |
| E27 | Nurse involved in resident medication and verbal abuse findings | |
| E1 | Nursing Home Administrator | Participated in exit conferences and findings review |
| E2 | Director of Nursing | Participated in exit conferences and findings review |
| E28 | Corporate Risk Management | Participated in exit conferences and findings review |
| E43 | Licensed Practical Nurse | Involved in protective eye shield order and communication device findings |
| E35 | Licensed Practical Nurse | Named in failure to report incident and verbal abuse findings |
| E53 | Certified Nurse Assistant | Named in incident and neglect findings |
| E59 | Certified Nurse Assistant | Named in incident and neglect findings |
| E61 | Certified Nurse Assistant | Named in incident and neglect findings |
| E66 | Certified Nurse Assistant | Named in incident and neglect findings |
| E8 | Certified Nurse Assistant | Named in shower and neglect findings |
| E10 | Unit Clerk | Named in incident involving resident and staff altercation |
| E12 | Nurse | Named in medication cart education |
| E13 | Nurse | Named in medication cart education |
| E14 | Licensed Practical Nurse | Named in admission assessment and medication cart education |
| E15 | Nurse | Named in medication cart education |
| E17 | Registered Nurse | Named in dental care and smoking evaluation findings |
| E18 | Certified Nurse Assistant | Named in orthotic device and smoking evaluation findings |
| E25 | Registered Nurse | Named in resident fall incident |
| E32 | Nurse | Named in resident care and charting findings |
| E34 | Rehab Director | Named in orthotic device findings |
| E36 | Certified Nurse Assistant | Named in staffing and resident care findings |
| E39 | Certified Nurse Assistant | Named in incident reporting and verbal abuse findings |
| E40 | House Supervisor | Named in incident reporting and verbal abuse findings |
| E41 | Nurse | Named in incident reporting and verbal abuse findings |
| E42 | Social Worker | Named in advanced directive findings |
| E43 | Licensed Practical Nurse | Named in protective eye shield order findings |
| E46 | Registered Nurse | Named in food safety findings |
| E47 | Registered Nurse | Named in admission assessment findings |
| E53 | Certified Nurse Assistant | Named in resident fall and incontinence findings |
| E56 | Certified Nurse Assistant | Named in resident fall and incontinence findings |
| E57 | Doctor of Osteopathy | Named in resident fall and injury findings |
| E58 | Licensed Practical Nurse | Named in resident transfer findings |
| E63 | Licensed Practical Nurse | Named in admission assessment findings |
| E64 | Licensed Practical Nurse | Named in admission assessment findings |
| E65 | Licensed Practical Nurse | Named in admission assessment findings |
| E66 | Certified Nurse Assistant | Named in resident care and incident findings |
| E67 | Certified Nurse Assistant | Named in resident care and incident findings |
| E76 | Certified Nurse Assistant | Named in resident care and incident findings |
| E76 | Certified Nurse Assistant | Named in resident care and incident findings |
| E76 | Certified Nurse Assistant | Named in resident care and incident findings |
| E76 | Certified Nurse Assistant | Named in resident care and incident findings |
Inspection Report
Annual Inspection
Census: 168
Deficiencies: 22
Jun 8, 2023
Visit Reason
An unannounced Annual, Complaint and Emergency Preparedness survey was conducted at this facility from May 25, 2023 through June 8, 2023.
Findings
The deficiencies contained in this report are based on observations, interviews, review of residents' clinical records and review of other facility documentation. The facility census on the first day of the survey was 168 with a sample of 54 residents. Deficiencies were identified in areas including resident rights, care planning, quality of care, infection control, medication management, and safety.
Severity Breakdown
SS=B: 2
SS=D: 10
SS=E: 7
SS=G: 3
Deficiencies (22)
| Description | Severity |
|---|---|
| Facility failed to promote care for residents in a manner and environment that maintained or enhanced each resident's dignity and respect. | SS=B |
| Facility failed to provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. | SS=B |
| Facility failed to ensure residents' right to participate in planning their care. | SS=D |
| Facility failed to promote and facilitate resident self-determination through support of resident choice. | SS=D |
| Facility failed to help and support a sampled resident for self-determination who wanted to be transferred back to bed. | SS=D |
| Facility failed to provide a safe, clean, comfortable and homelike environment, including maintenance of air conditioning units and housekeeping. | SS=E |
| Facility failed to ensure proper follow-up of cleanliness of resident room floors. | SS=E |
| Facility failed to report allegations of abuse, neglect, exploitation or mistreatment to the State Survey Agency in a timely manner. | SS=D |
| Facility failed to notify the State Agency within two hours after an allegation of mistreatment for one out of 54 sampled residents. | SS=D |
| Facility failed to develop and implement a comprehensive person-centered care plan for each resident. | SS=D |
| Facility failed to ensure residents received care and services for toileting and grooming. | SS=D |
| Facility failed to ensure residents received proper treatment to maintain vision. | SS=G |
| Facility failed to ensure residents received adequate nursing care after an unwitnessed fall and failed to implement behavior care plan interventions. | SS=G |
| Facility failed to ensure residents received restorative services and proper use of orthotic devices. | SS=G |
| Facility failed to ensure residents received proper care for pressure ulcers. | SS=E |
| Facility failed to ensure residents received proper respiratory care including oxygen tubing changes and tracheostomy care. | SS=E |
| Facility failed to ensure residents received proper medication management and timely pharmacist review. | SS=E |
| Facility failed to ensure residents received proper psychotropic drug monitoring and PRN orders. | SS=D |
| Facility failed to ensure residents received proper insulin medication storage and administration. | SS=D |
| Facility failed to ensure residents received proper food service including meal accuracy and sanitation. | SS=D |
| Facility failed to ensure residents received proper infection prevention and control including annual review and surveillance. | SS=E |
| Facility failed to ensure residents received proper abuse, neglect, and exploitation training for staff. | SS=E |
Report Facts
Facility census: 168
Sample size: 54
Deficiencies cited: 22
Inspection Report
Complaint Investigation
Census: 150
Deficiencies: 2
Mar 10, 2022
Visit Reason
An unannounced complaint survey was conducted at the facility from March 3, 2022, through March 10, 2022, based on observations, interviews, and review of residents' clinical records and other documentation.
Findings
The facility failed to review and revise care plans for residents at risk for pressure ulcers and failed to ensure residents received necessary treatment and services to prevent new pressure ulcers. Deficient practices included lack of evidence of revising care plans to include alternating low air loss mattresses and heel boots, and failure to implement preventative measures resulting in residents acquiring pressure ulcers.
Complaint Details
The visit was complaint-related as an unannounced complaint survey was conducted. The deficiencies were based on observations, interviews, and clinical record reviews. The facility census on the first day was 150, with a survey sample of four residents.
Severity Breakdown
SS=D: 1
SS=G: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to review and revise care plans for pressure ulcer prevention and treatment. | SS=D |
| Failure to ensure residents received necessary treatment and services to prevent new pressure ulcers. | SS=G |
Report Facts
Facility census: 150
Survey sample: 4
Deficiency completion date: Mar 29, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sandy Thompson | Administrator | Provider's signature on the state survey report |
| E1 | Nursing Home Administrator (NHA) | Named in exit conference during findings review |
| E2 | Director of Nursing (DON) | Named in exit conference during findings review |
| E3 | Assistant Director of Nursing (ADON) | Named in exit conference during findings review |
| E4 | Director of Clinical Services | Named in exit conference during findings review |
| E5 | RN Risk Manager | Named in exit conference during findings review |
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