Deficiencies (last 6 years)
Deficiencies (over 6 years)
16.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
90% worse than Delaware average
Delaware average: 8.8 deficiencies/yearDeficiencies per year
36
27
18
9
0
Occupancy
Latest occupancy rate
97% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 0
Date: Oct 20, 2025
Visit Reason
An unannounced complaint survey was conducted at the facility from October 20, 2025, through October 21, 2025.
Complaint Details
The complaint investigation was unannounced and no deficiencies were found, indicating no substantiated deficient practice.
Findings
No deficient practice was identified during the survey. The survey sample included three residents.
Report Facts
Survey sample residents: 3
Inspection Report
Follow-Up
Census: 113
Deficiencies: 0
Date: 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
Routine
Deficiencies: 12
Date: Jan 23, 2025
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including resident care, abuse prevention, discharge planning, accident prevention, food service, infection control, and antibiotic stewardship.
Findings
The facility was found deficient in multiple areas including failure to ensure effective communication with a Spanish-speaking resident, failure to prevent physical abuse, failure to timely report abuse allegations, failure to provide written hospital transfer and bed hold notices, inadequate discharge planning, inadequate supervision leading to resident falls and injuries, failure to provide medically related social services, serving food at inappropriate temperatures, poor kitchen sanitation and food safety practices, improper wound care and infection control practices, and incomplete antibiotic stewardship documentation.
Deficiencies (12)
F 0552: The facility failed to ensure one Spanish-speaking resident was communicated with in a language they could understand, risking unmet care needs.
F 0600: The facility failed to protect two residents from physical abuse by another resident, resulting in injuries and requiring supervision.
F 0609: The facility failed to report an allegation of abuse within two hours to the state agency for one resident, risking harm to all residents.
F 0623: The facility failed to provide written notification of hospital transfer to one resident and their responsible party, risking lack of knowledge of transfer reasons and appeal rights.
F 0625: The facility failed to provide written notification of the bed hold policy to one resident and their responsible party, risking confusion about bed reservation during hospitalization.
F 0660: The facility failed to develop and implement individualized discharge care plans for two residents, risking confusion and unmet care needs.
F 0689: The facility failed to provide adequate supervision to prevent falls and burns for three residents, resulting in fractures and second-degree burns.
F 0742: The facility failed to provide medically related social services to meet the psychosocial needs of one resident with depression and one-to-one supervision.
F 0804: The facility failed to serve food that was palatable and at appropriate temperature for three residents, risking decreased quality of life.
F 0812: The facility failed to ensure kitchen sanitation, including clean walls and floors, proper cooling of leftovers, and temperature monitoring of cold storage units.
F 0880: The facility failed to complete wound care properly for one resident and failed to wear proper PPE when entering a COVID positive resident's room, risking infection spread.
F 0881: The facility failed to consistently implement the Antibiotic Stewardship Program, including incomplete documentation and lack of data analysis for improvement.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 3
Residents affected: 107
Residents affected: 1
Residents affected: 111
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN2 | Registered Nurse | Failed proper wound care technique and PPE use during wound care for resident R78 |
| CNA3 | Certified Nursing Assistant | Involved in fall incident with resident R40 due to inadequate assistance |
| CNA4 | Certified Nursing Assistant | Involved in hot water burn incident with resident R96 |
| RN5 | Registered Nurse | Witnessed alleged abuse incident involving resident R71 but delayed reporting |
| DON | Director of Nursing | Provided multiple interviews regarding incidents, policies, and corrective actions |
| IP | Infection Preventionist | Provided information on infection control and antibiotic stewardship program |
| DM | Dietary Manager | Provided information on food service issues and kitchen sanitation |
| SSD | Social Services Director | Responsible for resident psychosocial needs and discharge planning |
Inspection Report
Routine
Deficiencies: 12
Date: Jan 23, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident communication, abuse prevention, transfer and discharge notifications, accident prevention, psychosocial services, food palatability, infection control, and antibiotic stewardship.
Findings
The facility was found deficient in multiple areas including failure to communicate with a Spanish-speaking resident in their language, failure to prevent physical abuse by a resident, failure to timely report abuse allegations, failure to provide written transfer and bed hold notices, lack of individualized discharge care plans, inadequate supervision leading to resident falls and injuries, failure to provide medically related social services, serving food at inappropriate temperatures, poor kitchen sanitation and food safety practices, improper wound care and PPE use, and incomplete antibiotic stewardship documentation.
Deficiencies (12)
Failed to ensure one Spanish-speaking resident was communicated with in a language they could understand.
Failed to protect two residents from physical abuse by another resident causing potential harm to all residents.
Failed to timely report an allegation of abuse within two hours to the state agency for one resident.
Failed to provide written notification of hospital transfer to resident and responsible party for one resident.
Failed to provide written notification of bed hold policy to resident and responsible party for one resident.
Failed to develop and implement an effective discharge care plan for two residents.
Failed to provide adequate supervision to prevent falls and burns resulting in actual harm to three residents.
Failed to provide medically related social services to meet psychosocial needs of one resident.
Failed to serve food that was palatable and at appropriate temperature for three residents.
Failed to ensure cold storage units had temperature gauges, kitchen floors and walls were clean and in good repair, and leftovers were cooled correctly.
Failed to complete wound care properly and wear proper PPE when entering contact isolation room for one resident.
Failed to implement antibiotic stewardship program consistently including documentation and data analysis.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 3
Residents affected: 107
Residents affected: 1
Residents affected: 111
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN4 | Registered Nurse | Observed assisting resident R113 but only spoke English |
| RN8 | Registered Nurse | Interviewed regarding resident R113 communication and fall risk |
| CNA6 | Certified Nurse Aide | Interviewed about communication with resident R113 and supervision of resident R90 |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including communication, abuse reporting, supervision, discharge planning, wound care, and infection control |
| Administrator | Interviewed regarding abuse incidents, supervision, and reporting | |
| RN5 | Registered Nurse | Interviewed about failure to report abuse allegation |
| ADON | Assistant Director of Nursing | Interviewed regarding transfer notices and fall prevention |
| CNA3 | Certified Nursing Assistant | Involved in fall incident with resident R40 |
| CNA4 | Certified Nurse Aide | Involved in hot water burn incident with resident R96 |
| RN2 | Registered Nurse | Observed providing improper wound care to resident R78 |
| HSK1 | Housekeeper | Observed not following PPE protocol in COVID isolation room |
| IP | Infection Preventionist | Interviewed regarding wound care and antibiotic stewardship |
| DM | Dietary Manager | Interviewed regarding food temperature and kitchen sanitation |
| RD | Registered Dietitian | Interviewed regarding food palatability and kitchen sanitation |
| RN1 | Registered Nurse | Interviewed regarding microwave use policy |
| RN2 | Registered Nurse | Interviewed regarding fall prevention for resident R38 |
| LPN5 | Licensed Practical Nurse | Interviewed regarding fall incident of resident R38 |
| CNA2 | Certified Nurse Aide | Interviewed regarding fall risk and supervision of resident R38 |
| CNA7 | Certified Nurse Aide | Interviewed regarding fall risk and supervision of resident R38 |
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 10
Date: 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.
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.
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.
Deficiencies (10)
Failure to ensure one resident with limited English proficiency was fully informed and able to communicate, causing potential unmet care needs.
Failure to ensure two residents were free from physical abuse, including incidents of altercations and inadequate supervision.
Failure to report allegations of abuse timely and conduct proper investigations for seven residents.
Failure to provide required notice before transfer or discharge for one resident.
Failure to develop and implement effective discharge planning process for two residents.
Failure to ensure residents were free from accident hazards, including falls and injuries from burns.
Failure to provide treatment and services for mental/psychosocial concerns for residents with mental disorders.
Failure to provide food that was palatable, safe, and at appropriate temperature for residents.
Failure to maintain infection prevention and control program, including wound care and isolation precautions.
Failure to implement antibiotic stewardship program including monitoring and education.
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
Complaint Investigation
Deficiencies: 6
Date: Feb 12, 2024
Visit Reason
The inspection was conducted to investigate complaints and review compliance with care planning, PASARR screening, dental services, medication regimen reviews, range of motion and mobility care, and interdisciplinary team participation in care planning.
Complaint Details
The visit was complaint-related, focusing on issues such as failure to submit PASARR referrals, incomplete care plans, lack of interdisciplinary team input, inadequate range of motion care, medication regimen review policy deficiencies, and failure to provide dental services. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in multiple areas including failure to submit required PASARR referrals, incomplete and untimely care plans for residents, lack of interdisciplinary team input in care plan meetings, failure to provide appropriate range of motion and mobility care, inadequate medication regimen review policies, and failure to assist a resident in obtaining routine dental services.
Deficiencies (6)
Failed to ensure a referral for a PASARR screening was completed for one resident after new diagnoses were identified.
Failed to develop and implement a comprehensive person-centered care plan for identified needs for two residents.
Failed to have input from all required interdisciplinary team members at care plan meetings for six residents.
Failed to provide appropriate services, equipment, and assistance to maintain function and mobility for two residents.
Failed to develop policies and procedures for monthly medication regimen reviews that included time frames for responding to pharmacy recommendations.
Failed to assist a resident in obtaining routine dental services, with no evidence of dental consultation since admission.
Report Facts
Residents reviewed for care plans: 24
Residents affected by care plan deficiencies: 2
Residents affected by interdisciplinary team input deficiencies: 6
Residents affected by range of motion and mobility deficiencies: 2
Residents affected by dental services deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | NHA | Named in findings review and interviews related to care plan and interdisciplinary team deficiencies |
| E2 | DON | Named in findings review and interviews related to care plan and medication regimen review deficiencies |
| E3 | Corporate | Participated in exit conferences reviewing findings |
| E4 | ADON | Interviewed regarding dental services and care plan meetings |
| E6 | Social Worker | Interviewed regarding PASARR referral and care plan meeting participation |
| E7 | RN/Staff | Interviewed regarding medication regimen review policy |
| E8 | RN/UM | Interviewed regarding care plan meetings and wound care behavior |
| E10 | CNA | Interviewed regarding range of motion care and knee splint application |
| E11 | RN/UM | Interviewed regarding therapy training and knee splint application |
| E12 | DOT | Interviewed regarding range of motion care and palm protector use |
| E13 | PT | Interviewed regarding knee splints use |
| E14 | CNA | Interviewed regarding palm protector use |
| E15 | RN | Interviewed regarding palm protector use |
| S1 | PASARR State Authority | Provided email confirmation regarding PASARR referral requirement |
Inspection Report
Routine
Deficiencies: 3
Date: Feb 12, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to care planning, medication regimen review, and clinical record documentation at Complete Care at Silver Lake LLC.
Findings
The facility failed to ensure interdisciplinary team input in care plan meetings for multiple residents, lacked policies with specific timeframes for responding to pharmacy recommendations during medication regimen reviews, and had incomplete or inaccurate clinical records for some residents.
Deficiencies (3)
Failed to have input from all required interdisciplinary team members at residents' care plan meetings.
Failed to develop policies and procedures for monthly medication regimen reviews that included time frames for responding to pharmacy recommendations.
Failed to ensure resident clinical records were complete and accurately documented.
Report Facts
Residents reviewed: 24
Residents affected: 6
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | NHA | Named in findings review and interviews regarding care plan meetings and documentation |
| E2 | DON | Named in findings review and interviews regarding care plan meetings and medication regimen review |
| E3 | Corporate | Named in findings review during exit conference |
| E4 | ADON | Confirmed missing progress note for resident R61 |
| E5 | RN | Confirmed inaccurate pain assessment for resident R306 |
| E6 | Social Worker | Interviewed regarding care plan meeting attendance and documentation |
| E7 | RN/Staff | Interviewed regarding medication regimen review policy |
| E8 | Unit Manager | Interviewed regarding process for gathering information for care plan meetings |
Inspection Report
Deficiencies: 3
Date: Feb 12, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to care planning, medication regimen review, and medical record documentation at Complete Care at Silver Lake LLC.
Findings
The facility failed to ensure interdisciplinary team input in care plan meetings for multiple residents, lacked specific timeframes in medication regimen review policies, and did not maintain complete and accurate clinical records for some residents.
Deficiencies (3)
F 0657: The facility failed to have input from all required interdisciplinary team members at care plan meetings for six out of twenty-four residents reviewed.
F 0756: The facility failed to develop policies and procedures for monthly medication regimen reviews that included timeframes for responding to pharmacy recommendations.
F 0842: The facility failed to ensure that clinical records for two residents were complete and accurately documented according to accepted professional standards.
Report Facts
Residents reviewed: 24
Residents affected: 6
Residents reviewed: 25
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | NHA | Named in interviews and exit conferences related to care plan and medication regimen review findings |
| E2 | DON | Named in interviews and exit conferences related to care plan and medication regimen review findings |
| E3 | Corporate | Named in exit conference related to care plan findings |
| E4 | ADON | Confirmed missing progress note for resident R61 |
| E5 | RN | Confirmed inaccurate pain assessment for resident R306 |
| E6 | Social Worker | Interviewed regarding care plan meeting attendance and documentation |
| E7 | RN/Staff | Interviewed regarding medication regimen review policy |
| E8 | Unit Manager | Interviewed regarding care plan meeting information gathering process |
Inspection Report
Annual Inspection
Census: 109
Deficiencies: 6
Date: 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.
Deficiencies (6)
Failed to ensure referral for PASARR screening was completed for one resident.
Failed to develop and implement comprehensive person-centered care plans for identified needs of residents.
Failed to develop policies and procedures for monthly Medication Regimen Review (MRR) including time frames for pharmacy recommendations.
Failed to assist residents in obtaining routine dental services.
Failed to maintain accurate and complete resident records including pain assessments and encounter notes.
Failed to ensure residents with limited range of motion received appropriate treatment and services to prevent further decrease in mobility.
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
Routine
Deficiencies: 6
Date: Feb 12, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, care planning, medication regimen reviews, dental services, and range of motion maintenance at Complete Care at Silver Lake LLC.
Findings
The facility was found deficient in multiple areas including failure to submit required PASARR referrals, incomplete and untimely care plans for residents, lack of interdisciplinary team input in care planning, failure to provide appropriate range of motion care and equipment, inadequate medication regimen review policies, and failure to assist a resident in obtaining routine dental services.
Deficiencies (6)
F0644: The facility failed to ensure a referral for a PASARR screening was completed for one resident after new diagnoses were identified.
F0656: The facility failed to develop and implement a comprehensive person-centered care plan for two residents, including failure to address behavior problems and continuous oxygen use.
F0657: The facility failed to have input from all required interdisciplinary team members at care plan meetings for six residents.
F0688: The facility failed to provide appropriate services, equipment, and assistance to maintain function and mobility for two residents, including failure to apply knee splints and palm protectors.
F0756: The facility failed to develop policies and procedures for monthly medication regimen reviews that included time frames for responding to pharmacy recommendations.
F0791: The facility failed to assist one resident in obtaining routine dental services, with no evidence of dental consultation since admission.
Report Facts
Residents reviewed for care plans: 24
Residents affected by care plan input deficiency: 6
Residents affected by care plan development deficiency: 2
Residents affected by range of motion and mobility deficiency: 2
Residents affected by dental services deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | NHA (Nursing Home Administrator) | Named in multiple findings including care plan and policy deficiencies |
| E2 | DON (Director of Nursing) | Named in multiple findings including care plan and policy deficiencies |
| E3 | Corporate Representative | Participated in exit conferences reviewing findings |
| E4 | ADON (Assistant Director of Nursing) | Interviewed regarding dental services and care plan meetings |
| E6 | Social Worker | Interviewed regarding PASARR referral and care plan meetings |
| E7 | RN/Staff | Interviewed regarding medication regimen review policy |
| E8 | RN/UM (Unit Manager) | Interviewed regarding care plan meeting processes |
| E10 | CNA | Interviewed regarding failure to apply knee splints |
| E12 | DOT (Director of Therapy) | Interviewed regarding range of motion care and palm protectors |
| E14 | CNA | Interviewed regarding failure to apply palm protectors |
| E15 | RN | Interviewed regarding failure to apply palm protectors |
Inspection Report
Follow-Up
Census: 101
Deficiencies: 0
Date: 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
Deficiencies: 12
Date: Dec 9, 2022
Visit Reason
The inspection was conducted as a comprehensive annual survey of Complete Care at Silver Lake LLC to assess compliance with regulatory requirements and investigate specific care concerns.
Findings
The facility was found deficient in multiple areas including failure to complete comprehensive MDS assessments after hospital readmission, incomplete interdisciplinary team attendance at care plan conferences, inadequate respiratory assessments and interventions, failure to monitor medication side effects, failure to obtain monthly weights as ordered, failure to assess and treat constipation, failure to apply prescribed splints, improper feeding tube placement verification, medication storage and labeling issues, food service deficiencies, kitchen sanitation and equipment maintenance problems, and incomplete staff training on abuse prevention.
Deficiencies (12)
Failed to complete a comprehensive MDS assessment upon return from hospital and identify new care needs such as Foley catheter and feeding tube.
Lacked evidence that required interdisciplinary team members attended post-admission care plan conference.
Failed to complete comprehensive respiratory assessment and provide respiratory interventions for resident with acute respiratory status change.
Failed to assess for signs or symptoms of constipation and administer medications as ordered after no bowel movement for three days.
Failed to monitor sedation side effects for Melatonin and failed to obtain monthly weights as ordered, leading to uncertainty about weight loss onset.
Failed to apply left elbow splint as ordered to prevent further decrease in range of motion.
Failed to correctly verify feeding tube placement prior to medication administration.
Failed to ensure medications were stored and labeled properly, including undated opened insulin pens.
Failed to ensure residents received selected food from the menu as ordered.
Failed to prevent mold in high moisture areas, ensure safe storage of food and beverages, and maintain correct sanitizing solution concentration.
Failed to maintain essential kitchen equipment in safe operating condition, including damaged walk-in freezer door and ice accumulation.
Failed to ensure required staff training on abuse, neglect, and exploitation was completed for one staff member.
Report Facts
Residents reviewed for comprehensive MDS assessment: 28
Residents reviewed for care plan conferences: 28
Residents reviewed for hospitalization: 1
Residents reviewed for constipation: 1
Residents reviewed for unnecessary medications: 6
Residents reviewed for weight loss: 5
Periods of no bowel movement >3 days: 3
Shifts with no bowel movement and no medication administered: 15
Shifts with no bowel movement and no medication administered: 16
Shifts with no bowel movement and no medication administered: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E14 | RNAC | Confirmed failure to complete comprehensive MDS assessment upon hospital return |
| E1 | NHA | Reviewed findings at exit conferences |
| E2 | DON | Reviewed findings at exit conferences |
| E12 | RN | Documented respiratory distress and lack of oxygen saturation monitoring for R211 |
| E6 | IP | Confirmed medication monitoring issues and food service deficiencies |
| E20 | Agency RN | Failed to apply left elbow splint for R39 |
| E10 | RN | Used incorrect method to verify feeding tube placement |
| E17 | OT | Failed to complete required abuse, neglect, and exploitation training |
| E25 | LPN | Confirmed undated opened insulin pen found in medication cart |
| E22 | Dietary Aide | Confirmed resident did not receive selected food items |
| E15 | Food Service Director | Confirmed kitchen sanitation and equipment deficiencies |
Inspection Report
Annual Inspection
Census: 105
Deficiencies: 14
Date: 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)
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
Annual Inspection
Deficiencies: 10
Date: Dec 9, 2022
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to complete comprehensive assessments after hospital readmission, incomplete interdisciplinary team participation in care planning, inadequate respiratory assessments and interventions, failure to monitor medication side effects, failure to obtain required resident weights, failure to assess and treat constipation, failure to apply prescribed splints, improper feeding tube placement verification, medication storage and labeling issues, failure to provide residents with selected menu items, food safety and sanitation deficiencies, malfunctioning kitchen equipment, and incomplete staff training on abuse prevention.
Deficiencies (10)
F0637: The facility failed to complete a comprehensive MDS assessment upon return from the hospital for resident R260, missing new care needs including Foley catheter and feeding tube.
F0657: The facility lacked evidence that required interdisciplinary team members attended the post-admission care plan conference for resident R26.
F0684: The facility failed to provide appropriate respiratory assessment and interventions for resident R211 with acute respiratory status change, and failed to assess constipation, monitor sedation for Melatonin use, and obtain required weights for other residents.
F0688: The facility failed to ensure the left elbow splint was applied as ordered for resident R39 to maintain range of motion.
F0693: The facility failed to correctly verify feeding tube placement prior to medication administration for resident R61.
F0761: The facility failed to ensure medications were stored and labeled properly, including undated opened insulin pens in medication carts.
F0803: The facility failed to ensure residents received the selected food from the menu for resident R40.
F0812: The facility failed to prevent mold in high moisture areas, ensure safe food storage with proper labeling, and maintain correct sanitizing solution concentration in the kitchen.
F0908: The facility failed to maintain essential kitchen equipment in safe operating condition, including damaged freezer door and ice buildup.
F0943: The facility failed to ensure required training on abuse, neglect, and exploitation was completed for staff member E17.
Report Facts
Residents reviewed: 28
Periods without bowel movement: 3
Medication carts reviewed: 2
Sanitizer buckets: 3
Opened containers without date labels: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E10 | Registered Nurse | Failed to use ordered method to verify feeding tube placement prior to medication administration |
| E17 | Occupational Therapist | Did not complete required abuse, neglect, and exploitation training timely |
| E20 | Agency Registered Nurse | Failed to apply left elbow splint for resident R39 during observation |
| E12 | Registered Nurse | Documented respiratory status and failed to initiate oxygen interventions for resident R211 |
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 0
Date: 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.
Complaint Details
The survey included a complaint investigation component, but no deficiencies were identified.
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.
Report Facts
Survey sample size: 12
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
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
Date: 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.
Complaint Details
The survey was complaint-related and included a focused infection control review. Specific substantiation status is not stated.
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.
Deficiencies (2)
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
Date: 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)
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
Date: 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.
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.
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.
Deficiencies (2)
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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