Inspection Report Summary
The most recent inspection on December 6, 2024, identified deficiencies related to resident rights, food safety, hospice services, infection control, and staff training. Earlier inspections showed a pattern of various issues including care planning, medication management, emergency preparedness, and reporting requirements, with a follow-up survey in February 2024 finding no deficiencies and indicating substantial compliance at that time. The main themes across deficiencies involved infection prevention, food service practices, and staff education on dementia and abuse prevention. Complaint investigations were unsubstantiated or did not result in deficiencies. The facility’s inspection history shows some fluctuations, with improvements noted after the 2023 annual survey but new issues identified in the most recent 2024 inspection.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
38% better than Delaware average
Delaware average: 8.8 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
29 residents
Based on a December 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 29
Deficiencies: 7
Dec 6, 2024
Visit Reason
An unannounced Annual, Complaint, and Emergency Preparedness Survey was conducted at the facility from December 3, 2024, through December 6, 2024.
Findings
The survey identified deficiencies based on observations, interviews, and document review. Deficiencies included issues with resident rights, food safety, hospice services, infection control, and abuse prevention. Plans of correction with completion dates were provided for each deficiency.
Severity Breakdown
SS=D: 4
SS=F: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| Food service employees utilized gloves while feeding residents violating resident's dignity in their home environment. | SS=D |
| Facility failed to ensure food was stored, prepared, and served in a manner that prevents food borne illness to residents. | SS=F |
| Facility failed to ensure hospice services met regulatory requirements including communication, plan of care, and staff education. | SS=D |
| Facility failed to establish and maintain an infection prevention and control program. | SS=F |
| Facility failed to handle, store, process, and transport linens to prevent spread of infection. | SS=F |
| Facility failed to provide training to staff on dementia management. | SS=D |
| Facility failed to provide training to staff on abuse, neglect, and exploitation prevention. | SS=D |
Report Facts
Facility census: 29
Sample size: 16
Deficiency completion dates: Jan 31, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Dennison | LNHA | Provider's signature on pages 1-3 |
| E1 | NHA | Participated in exit conferences and review of findings |
| E2 | DON | Participated in exit conferences and review of findings |
| E3 | ADON | Participated in exit conferences and review of findings |
| E10 | Food Service Assistant | Interviewed regarding food storage and safety findings |
| E11 | Dietary Aide | Interviewed regarding food storage and safety findings |
| E12 | Dietary Aide | Interviewed regarding food storage and safety findings |
| E14 | Supply Supervisor | Interviewed regarding laundry and infection control findings |
| E15 | HR Director | Interviewed regarding dementia training findings |
| E16 | Laundress | Interviewed regarding laundry and infection control findings |
| E17 | Laundress | Interviewed regarding laundry and infection control findings |
Inspection Report
Follow-Up
Census: 33
Deficiencies: 0
Feb 15, 2024
Visit Reason
An unannounced Follow-Up Survey to the Annual, Complaint and Emergency Preparedness Survey ending 12/5/23 was conducted at this facility from February 14, 2024, through February 15, 2024.
Findings
The facility was found to have regained substantial compliance with 42CFR Part 483, Subpart B, Requirements for Long Term Care Facilities as of February 15, 2024. No deficient practice was identified.
Report Facts
Facility census: 33
Sample size: 14
Inspection Report
Annual Inspection
Census: 34
Deficiencies: 10
Dec 5, 2023
Visit Reason
An unannounced Annual, Complaint, and Emergency Preparedness Survey was conducted at the facility from November 28, 2023 through December 5, 2023, including an Extended Survey on December 5, 2023.
Findings
The survey identified multiple deficiencies related to resident elopement reporting, notification of changes, admission physician orders, accuracy of assessments, baseline care plans, care plan timing and revision, free of accident hazards, nurse aide performance reviews, and immunizations. The facility failed to report a resident elopement, failed to have physician orders for immediate care, and had issues with fall risk assessments and care planning.
Deficiencies (10)
| Description |
|---|
| Failure to report resident elopement to the State Agency as required. |
| Failure to notify physician and family representative of resident's fall and potential need for further evaluation. |
| Failure to have admission physician orders for immediate care for a resident's fractured finger. |
| Failure to ensure accuracy of resident assessments, including diagnosis of septicemia. |
| Failure to develop and implement baseline care plans including necessary instructions and goals. |
| Failure to timely revise care plans for residents with pressure ulcers and other conditions. |
| Failure to ensure resident environment is free of accident hazards and provide adequate supervision and assistive devices to prevent accidents. |
| Failure to complete nurse aide performance reviews annually for all CNAs. |
| Failure to provide influenza and pneumococcal immunizations according to policy and document refusals or contraindications. |
| Failure to provide required in-service training for nurse aides. |
Report Facts
Facility census: 34
Sample size: 15
Deficiency completion dates: Jan 18, 2024
Resident falls reviewed: 3
Nurse Aide Performance Review interval: 12
Fall risk assessment score: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Dennis | Administrator | Signed the state survey report and plan of correction. |
| E1 | Nursing Home Administrator (NHA) | Interviewed and involved in exit conferences and findings review. |
| E2 | Director of Nursing (DON) | Interviewed and involved in exit conferences and findings review. |
| E6 | Assistant Director of Nursing (ADON) | Interviewed and involved in exit conferences and findings review. |
| E5 | Registered Nurse (RN) Supervisor | Provided statements regarding resident elopement and wandering guard. |
| E8 | Registered Nurse (RN) | Interviewed regarding resident elopement incident. |
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 5
Nov 23, 2021
Visit Reason
An unannounced annual and complaint survey was conducted at the facility from November 18, 2021 through November 23, 2021, including an Emergency Preparedness survey.
Findings
The facility was found deficient in emergency preparedness training for new hires and failed to develop a care plan for sleeplessness for one resident. Medication regimen reviews were irregular and lacked proper physician responses. The facility also failed to ensure monitoring for unnecessary drug use and adequate monitoring for sleep supplements.
Deficiencies (5)
| Description |
|---|
| Failure to provide initial emergency preparedness training to three staff members upon hire. |
| Failure to develop a care plan for sleeplessness for one resident (R16). |
| Irregular medication regimen review and lack of physician response for one resident (R6). |
| Failure to ensure medication regimen is free from unnecessary drugs. |
| Failure to adequately monitor sleep supplements and behavior monitoring for sleeplessness for one resident (R16). |
Report Facts
Facility census: 36
Survey dates: 6
Survey sample: 23
Deficiency completion dates: Dec 22, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kim M. Carr | Administrator | Signed the administrator's plan for correction of deficiencies. |
| E1 | Nursing Home Administrator involved in exit conference and review of findings. | |
| E2 | Director of Nursing | Conducted medication regimen review and involved in interviews and exit conference. |
| E8 | Staff member without record of initial emergency preparedness training. | |
| E12 | Staff member without record of initial emergency preparedness training. | |
| E13 | Staff member without record of initial emergency preparedness training. |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 0
Oct 3, 2019
Visit Reason
An unannounced complaint investigation survey was conducted at the facility from October 2, 2019 through October 3, 2019.
Findings
No deficiencies were cited during the survey. The facility census on the first day of the survey was 34, with a survey sample of three residents.
Complaint Details
The survey was an unannounced complaint investigation. No deficiencies were cited at the time of the survey.
Report Facts
Census: 34
Survey sample: 3
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