Deficiencies per Year
16
12
8
4
0
High
Moderate
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 0
Oct 20, 2025
Visit Reason
An unannounced complaint survey was conducted at the facility from October 20, 2025, through October 21, 2025.
Findings
No deficient practice was identified during the survey. The survey sample included three residents.
Complaint Details
The complaint investigation was unannounced and no deficiencies were found, indicating no substantiated deficient practice.
Report Facts
Survey sample residents: 3
Inspection Report
Follow-Up
Census: 113
Deficiencies: 0
Mar 20, 2025
Visit Reason
An unannounced follow-up survey was conducted at the facility from March 20, 2025, through March 21, 2025 to verify correction of previous deficiencies.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities. No deficiencies were identified at the time of the survey.
Report Facts
Survey sample size: 27
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 10
Jan 23, 2025
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 included an Emergency Preparedness survey and complaint investigation.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified related to residents' rights, freedom from abuse and neglect, reporting of alleged violations, notice requirements before transfer/discharge, discharge planning process, free of accident hazards, treatment and services for mental/psychosocial concerns, food safety, infection prevention and control, and antibiotic stewardship program. The facility submitted plans of correction for all deficiencies.
Complaint Details
The complaint investigation substantiated multiple deficiencies including failure to ensure residents' rights, freedom from abuse, proper reporting of alleged violations, and adequate care planning. Specific incidents involved residents R24, R82, R90, R113, and others. The facility failed to report abuse allegations timely and failed to protect residents from harm. The facility was required to conduct re-education, audits, and implement corrective actions.
Severity Breakdown
SS=D: 7
SS=G: 1
SS=E: 1
SS=F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to ensure one resident with limited English proficiency was fully informed and able to communicate, causing potential unmet care needs. | SS=D |
| Failure to ensure two residents were free from physical abuse, including incidents of altercations and inadequate supervision. | SS=D |
| Failure to report allegations of abuse timely and conduct proper investigations for seven residents. | SS=D |
| Failure to provide required notice before transfer or discharge for one resident. | SS=D |
| Failure to develop and implement effective discharge planning process for two residents. | SS=D |
| Failure to ensure residents were free from accident hazards, including falls and injuries from burns. | SS=G |
| Failure to provide treatment and services for mental/psychosocial concerns for residents with mental disorders. | SS=D |
| Failure to provide food that was palatable, safe, and at appropriate temperature for residents. | SS=D |
| Failure to maintain infection prevention and control program, including wound care and isolation precautions. | SS=E |
| Failure to implement antibiotic stewardship program including monitoring and education. | SS=F |
Report Facts
Survey Census: 111
Sample Size: 32
Supplemental Residents: 9
Deficiencies cited: 10
Residents involved in abuse allegations: 7
Residents reviewed for transfer notice: 32
Residents reviewed for discharge planning: 32
Residents reviewed for accident hazards: 32
Residents reviewed for infection control: 32
Residents at risk for antibiotic adverse events: 111
Inspection Report
Annual Inspection
Census: 109
Deficiencies: 6
Feb 12, 2024
Visit Reason
An unannounced Annual, Complaint and Emergency Preparedness survey was conducted at the facility from February 5, 2024 through February 12, 2024. The survey included review of residents' clinical records, interviews, and facility documents.
Findings
The survey identified deficiencies related to PASARR coordination, comprehensive care planning, drug regimen review, dental services, resident records, and mobility care. The facility submitted plans of correction and implemented measures to address these deficiencies.
Severity Breakdown
Level 2: 5
Level 3: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure referral for PASARR screening was completed for one resident. | Level 2 |
| Failed to develop and implement comprehensive person-centered care plans for identified needs of residents. | Level 2 |
| Failed to develop policies and procedures for monthly Medication Regimen Review (MRR) including time frames for pharmacy recommendations. | Level 3 |
| Failed to assist residents in obtaining routine dental services. | Level 2 |
| Failed to maintain accurate and complete resident records including pain assessments and encounter notes. | Level 2 |
| Failed to ensure residents with limited range of motion received appropriate treatment and services to prevent further decrease in mobility. | Level 2 |
Report Facts
Facility census: 109
Survey sample size: 24
Completion date for plan of correction: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator (NHA) | Interviewed and confirmed lack of care plans and documentation |
| E2 | Director of Nursing (DON) | Interviewed and confirmed lack of documentation and care plan issues |
| E3 | Corporate Representative | Participated in exit conference and review of findings |
| E6 | Social Worker | Confirmed facility did not submit PASARR request and issues with care plan meetings |
| E7 | Registered Nurse (RN)/Staff | Interviewed regarding medication regimen review policy |
| E8 | Unit Manager | Interviewed regarding care plan meetings and documentation |
| E9 | Registered Nurse (RN) | Interviewed regarding resident behavior and wound care |
| E10 | Certified Nursing Assistant (CNA) | Interviewed regarding splint application and resident care |
| E11 | Registered Nurse (RN)/Unit Manager | Interviewed regarding therapy training and splint application |
| E12 | Director of Therapy (DOT) | Interviewed regarding splint use and resident care |
| E13 | Physical Therapist (PT) | Interviewed regarding splint use and resident care |
| E14 | Certified Nursing Assistant (CNA) | Interviewed regarding resident care and splint application |
| E15 | Registered Nurse (RN) | Interviewed regarding resident care and splint use |
| R77 | Resident with PASARR and dental service deficiencies | |
| R66 | Resident with care plan and medication regimen deficiencies | |
| R269 | Resident with care plan and wound dressing deficiencies | |
| R39 | Resident with mobility and splinting deficiencies | |
| R62 | Resident with mobility and splinting deficiencies | |
| R61 | Resident with record documentation deficiencies | |
| R306 | Resident with record documentation deficiencies |
Inspection Report
Follow-Up
Census: 101
Deficiencies: 0
Feb 8, 2023
Visit Reason
An unannounced Follow-up Survey to the Annual, Complaint and Emergency Preparedness Survey ending December 9, 2022, was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care as of January 23, 2023. No deficiencies were identified at the time of the survey.
Report Facts
Sample size: 18
Inspection Report
Annual Inspection
Census: 105
Deficiencies: 14
Dec 9, 2022
Visit Reason
An unannounced Annual and Complaint Survey was conducted at the facility from December 2, 2022 through December 9, 2022. The survey included observations, interviews, review of clinical records, and other facility documentation.
Findings
The survey identified multiple deficiencies related to personnel records, dementia training, care plan timing and revision, quality of care, medication management, abuse prevention training, and food safety. The facility failed to meet several regulatory requirements as evidenced by missing documentation, incomplete assessments, and inadequate staff training.
Deficiencies (14)
| Description |
|---|
| Personnel records lacked evidence of criminal background checks, mandatory drug testing, and adult abuse registry checks for one employee. |
| Facility failed to ensure required dementia training was completed and documented for new hires. |
| Facility failed to complete a comprehensive MDS assessment upon return from hospital for one resident and failed to identify significant changes in condition. |
| Facility failed to ensure post-admission care plan conferences included required interdisciplinary team members. |
| Facility failed to complete a comprehensive respiratory assessment for one resident with acute respiratory status change. |
| Facility failed to assess residents for constipation and follow physician orders for monitoring sedation and weight loss. |
| Facility failed to ensure appropriate mobility services and treatment for residents with limited range of motion. |
| Facility failed to provide appropriate care and treatment for residents with splints and failed to monitor skin integrity. |
| Facility failed to ensure proper placement and verification of enteral feeding tubes for one resident. |
| Facility failed to properly label and store drugs and biologicals in medication carts. |
| Facility failed to ensure menus met nutritional adequacy and failed to provide selected food items to residents. |
| Facility failed to ensure proper food procurement, storage, preparation, and sanitation in the kitchen, including presence of mold and improperly labeled food items. |
| Facility failed to maintain essential kitchen equipment in safe operating condition, including freezer door gasket and temperature logs. |
| Facility failed to provide required abuse, neglect, and exploitation training to staff. |
Report Facts
Facility census: 105
Survey sample size: 49
Employees reviewed: 13
Residents reviewed for comprehensive MDS assessment: 28
Residents reviewed for ROM (Range of Motion): 2
Insulin pens discarded: 0
Food items missing: 2
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 0
Aug 24, 2021
Visit Reason
An unannounced COVID-19 Focused Infection Control Survey and Complaint Survey was conducted by the State of Delaware Division of Health Care Quality from August 23, 2021 through August 24, 2021.
Findings
The facility was found to be in compliance with 42 CFR §483.80 and had implemented the CMS and CDC recommended practices to prepare for COVID-19. No deficiencies were identified at the time of the survey.
Complaint Details
The survey included a complaint investigation component, but no deficiencies were identified.
Report Facts
Survey sample size: 12
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 1
Mar 29, 2021
Visit Reason
An unannounced Complaint Survey was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection from March 22, 2021 through March 29, 2021.
Findings
The facility failed to notify the resident representative of unavoidable, continued significant changes in weight loss for one resident (R1). The clinical record lacked evidence of timely notification to the resident representative regarding ongoing weight loss, despite significant documented weight loss over several months.
Complaint Details
The complaint investigation found that the facility did not notify the resident representative of significant weight loss changes for resident R1 in a timely manner, despite documented evidence of weight loss and clinical record reviews. The facility acknowledged the deficiency and outlined corrective actions including audits and staff education.
Deficiencies (1)
| Description |
|---|
| Failure to inform resident representative regarding unavoidable, continued significant changes in weight loss for resident R1. |
Report Facts
Facility census: 98
Survey sample: 4
Weight loss: 105.3
Admission weight: 283.1
Weight on 3/18/2021: 177.8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator (NHA) | Confirmed evidence of lack of notification to resident representative |
| E2 | Director of Nursing (DON) | Participated in exit conference reviewing findings |
| E3 | Registered Nurse (RN), Unit Manager (UM) | Interviewed regarding notification responsibilities for resident representative |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 2
Feb 11, 2021
Visit Reason
An unannounced COVID-19 Focused Infection Control Survey and Complaint Survey was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection from February 5, 2021 through February 11, 2021.
Findings
The survey identified deficiencies related to the quality assessment and assurance committee failing to meet quarterly, and infection prevention and control program deficiencies including incomplete screening of employees prior to entrance into the facility.
Complaint Details
The survey was complaint-related and included a focused infection control review. Specific substantiation status is not stated.
Deficiencies (2)
| Description |
|---|
| The quality assessment and assurance committee failed to meet at least quarterly to identify necessary quality assessment and assurance activities. |
| The facility failed to thoroughly screen employees prior to their entrance into the facility, including incomplete screening logs and failure to follow infection control guidance. |
Report Facts
Survey sample size: 9
Quarterly meetings reviewed: 4
Meetings with missing required members: 3
Facility census: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator (NHA) | Interviewed and confirmed committee members were not consistently present at QAA meetings |
| E2 | Director of Nursing (DON) | Interviewed and confirmed incomplete screening logs and reviewed findings during exit conference |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Sep 16, 2020
Visit Reason
The survey was a COVID-19 Focused Infection Control Desk Review conducted by the Delaware Division of Health Care Quality from September 11 to September 16, 2020, to assess compliance with COVID-19 testing requirements for staff.
Findings
The facility failed to comply with bi-weekly staff COVID-19 testing as required by Division of Public Health guidance, missing testing dates in August 2020. A root cause analysis revealed errors in the cadence of state employee testing and incomplete reporting of staff testing results.
Deficiencies (1)
| Description |
|---|
| Failure to conduct bi-weekly staff COVID-19 testing consistent with Division of Public Health guidance. |
Report Facts
Dates missed for staff testing: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Warren Burke | CED | Provider's signature on the report |
| E2 | Director of Nursing (DON) contacted about missing staff COVID-19 testing data | |
| E3 | Infection Control Nurse | Provided testing dates and communicated with DHCQ about bi-weekly testing |
| E1 | Nursing Home Administrator (NHA) | Responded to DHCQ inquiries about missed testing dates and scheduling |
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 2
Jul 15, 2020
Visit Reason
An unannounced complaint survey was conducted at the facility from July 2, 2020 through July 15, 2020 to investigate complaints regarding discharge planning and COVID-19 transmission precautions.
Findings
The facility failed to involve the resident and resident representative in the development of the discharge plan and did not communicate properly with the responsible party about the resident's transfer. The resident was transferred to a hospital due to COVID-19 and was not allowed to return to the facility, which did not have other COVID-19 positive residents. The facility was found noncompliant with CDC, State, and facility guidelines concerning isolation during the pandemic.
Complaint Details
The complaint investigation found that Resident R1 was discharged without proper involvement of the resident and family in discharge planning. The resident was transferred to the hospital due to COVID-19 and was not allowed to return to the facility, which lacked other COVID-19 positive residents. The facility requested and received a waiver to transfer the resident to another facility with multiple COVID-19 positive residents. Family members expressed concerns about communication failures and the handling of the resident's transfer.
Deficiencies (2)
| Description |
|---|
| Failure to involve the resident and resident representative in the development of the discharge plan and inform them of the final plan. |
| Noncompliance with COVID-19 transmission-based precautions leading to resident transfer to hospital and risk to other residents. |
Report Facts
Survey duration days: 14
Census: 100
Survey sample size: 3
BIMS score: 7
Date of resident discharge: Apr 16, 2020
Date letter sent to family: May 28, 2020
Date waiver approved: May 12, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator (NHA) | Explained resident transfer and noncompliance with COVID-19 precautions |
| E2 | Director of Nursing (DON) | Documented nursing notes regarding resident condition and transfer |
| E3 | Medical Director (MD) | Involved in decision to send resident to ER |
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