Inspection Report Summary
The most recent inspection on May 20, 2025, identified multiple deficiencies related to resident rights, abuse reporting, care planning, medication management, infection control, and quality of care. Earlier inspections showed a pattern of issues including incomplete care plans, medication monitoring, personnel recordkeeping, and emergency preparedness, with some deficiencies recurring over time. Complaint investigations included a substantiated case involving failure to report abuse allegations timely and protect residents from neglect. Enforcement actions such as fines or license suspensions were not listed in the available reports. The inspection history indicates ongoing challenges with regulatory compliance, with no clear improvement trend evident.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
14.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
65% worse than Delaware average
Delaware average: 8.8 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
72 residents
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 3
May 20, 2025
Visit Reason
The inspection was conducted to investigate complaints related to failure to offer residents the opportunity to formulate advance directives, failure to timely report allegations of abuse, and failure to follow a physician's medication order.
Findings
The facility failed to offer three residents (R38, R76, and R234) the opportunity to formulate an advance directive. The facility also failed to report an allegation of abuse involving resident R24 to the State Agency within the required two-hour timeframe. Additionally, the facility failed to follow a physician's order for resident R38 by administering medication despite parameters indicating it should be held.
Complaint Details
The complaint investigation found substantiated deficiencies including failure to offer advance directives to residents, delayed reporting of abuse allegations, and failure to follow physician medication orders.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to offer an opportunity to formulate an advance directive for three residents (R38, R76, and R234). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report allegations of abuse to the State Agency within two hours for one resident (R24). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow a physician's order by administering metoprolol tartrate to resident R38 when systolic blood pressure and heart rate were outside prescribed parameters. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for advance directives: 4
Residents affected by advance directive deficiency: 3
Residents reviewed for abuse: 2
Residents affected by abuse reporting deficiency: 1
Residents reviewed for medication order compliance: 24
Residents affected by medication order deficiency: 1
Days delay in abuse report: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director (ED) | Reviewed findings with surveyors; confirmed physician discusses advanced care options. |
| E2 | Director of Nursing (DON) | Reviewed findings with surveyors; confirmed physician discusses advanced care options; confirmed investigation initiation for abuse allegation. |
| E5 | Nurse Practitioner (NP) | Confirmed expectation to hold medication when parameters not met and report to provider; unaware medication was administered to R38 despite parameters. |
| E10 | Registered Nurse (RN) | Interviewed resident R24 regarding abuse allegation; notified DON and conducted investigation. |
| E13 | Licensed Practical Nurse (LPN) | Confirmed admitting nurse responsible for resident assessments. |
| E15 | Registered Nurse (RN) | Confirmed expectation to hold medication when parameters not met and report to provider; confirmed medication was administered to R38. |
| E18 | Clinical Liaison | Confirmed admitting nurse responsible to review admission documents with residents. |
Inspection Report
Annual Inspection
Census: 72
Deficiencies: 12
May 20, 2025
Visit Reason
An unannounced Annual and Complaint survey was conducted at the facility from May 12, 2025, through May 20, 2025, based on interviews, record review, and other facility documentation.
Findings
The survey identified multiple deficiencies related to resident rights, abuse reporting, comprehensive care plans, medication management, infection control, and quality of care. The facility failed to ensure residents were treated with respect and dignity, timely reporting of abuse allegations, and proper implementation of care plans and medication protocols.
Complaint Details
The complaint investigation was substantiated with findings including failure to report abuse allegations timely and failure to protect residents from abuse and neglect.
Severity Breakdown
Level 2: 12
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to treat residents with respect and dignity, including staff entering rooms without knocking or waiting for permission. | Level 2 |
| Failure to ensure a responsible party was involved in code status decisions for a cognitively impaired resident. | Level 2 |
| Failure to offer residents the opportunity to formulate an advance directive. | Level 2 |
| Failure to report allegations of abuse to the State Agency within required timeframes. | Level 2 |
| Failure to develop a comprehensive person-centered care plan for an identified care area. | Level 2 |
| Failure to provide services that meet professional standards, including admission assessments by Licensed Practical Nurses. | Level 2 |
| Failure to follow physician's orders related to blood pressure management. | Level 2 |
| Failure to provide individualized bowel and bladder continence care and antibiotic therapy for residents with urinary catheters. | Level 2 |
| Failure to limit psychotropic medication to 14 days and provide proper stop dates for PRN medications. | Level 2 |
| Failure to promptly notify ordering practitioners of laboratory results outside clinical reference ranges. | Level 2 |
| Failure to use enhanced barrier precautions consistently for a resident with a central line. | Level 2 |
| Failure to establish and maintain an infection prevention and control program that includes required elements. | Level 2 |
Report Facts
Residents present: 72
Survey sample size: 29
Deficiency completion dates: 7
BIMS score: 5
Medication stop date: 14
Audit sample size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E14 | PTA | Observed entering resident rooms without waiting for permission |
| E15 | RN | Observed entering resident rooms without waiting for permission |
| E1 | Executive Director | Reviewed findings with surveyors and involved in corrective action plans |
| E2 | Director of Nursing | Reviewed findings with surveyors and involved in corrective action plans |
| E5 | NP | Interviewed regarding cognitive assessments and medication orders |
| E13 | LPN | Observed medication administration and admission assessments |
| E17 | Housekeeping | Observed entering resident rooms without waiting for permission |
| E78 | Resident | Subject of abuse allegation and medication review |
Inspection Report
Annual Inspection
Deficiencies: 5
Jun 13, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, treatment, and facility operations at Center at Eden Hill, LLC.
Findings
The facility was found deficient in multiple areas including failure to develop a care plan for ear wax buildup, failure to provide nail care, failure to administer ear drops as ordered, failure to provide respiratory care with proper physician orders, and inadequate monitoring of antipsychotic medication side effects.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to develop a care plan to address wax build up in the ears for resident R46. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide nail care for resident R3, resulting in long fingernails with dark encrusted debris. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to administer Debrox ear drops as ordered for resident R46. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide respiratory care with a valid physician's order for oxygen therapy for resident R51. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure adequate monitoring of antipsychotic medication side effects for resident R40. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for care plans: 45
Residents reviewed for ADL: 3
Residents reviewed for hearing: 1
Residents reviewed for respiratory care: 1
Residents reviewed for unnecessary medication: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E19 | RN, UM | Confirmed lack of care plan for ear wax buildup and absence of daily monitoring for antipsychotic medication side effects |
| E20 | CNA | Observed providing care and confirmed nail care practices |
| E21 | RN | Interviewed regarding resident R46's ear pain and medication |
| E2 | DON | Confirmed findings during exit conference and lack of physician order for oxygen therapy |
| E1 | NHA | Participated in exit conference reviewing findings |
| E5 | LPN | Confirmed lack of physician order for oxygen therapy for resident R51 |
Inspection Report
Annual Inspection
Census: 69
Deficiencies: 5
Jun 13, 2024
Visit Reason
An unannounced annual and complaint survey was conducted from June 6, 2024 through June 13, 2024, including an Emergency Preparedness survey, to assess compliance with federal and state regulations.
Findings
The facility had multiple deficiencies including failure to maintain complete personnel records with mandatory screenings for some employees, failure to develop a person-centered care plan for a resident, inadequate nail care for residents, failure to provide respiratory care consistent with professional standards, and failure to ensure proper monitoring and documentation of psychotropic medication use.
Severity Breakdown
F 656: 1
F 677: 1
F 695: 1
F 758: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Personnel records lacked evidence of mandatory tuberculosis screening, criminal background check, drug testing, and adult abuse registry check for one employee. | — |
| Facility failed to develop a person-centered care plan for a resident to address wax buildup in the ears. | F 656 |
| Facility failed to provide nail care to residents, resulting in long fingernails with dark encrusted debris. | F 677 |
| Facility failed to provide respiratory care consistent with professional standards for a resident requiring oxygen therapy. | F 695 |
| Facility failed to ensure adequate monitoring and documentation of psychotropic medication use, including AIMS assessments and PRN orders. | F 758 |
Report Facts
Facility census: 69
Investigative sample: 45
Employees reviewed: 8
Residents reviewed for care plans: 45
Residents reviewed for ADL: 3
Residents reviewed for respiratory care: 1
Residents reviewed for psychotropic medication: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator (NHA) | Interviewed regarding personnel records and findings |
| E2 | Director of Nursing (DON) | Interviewed and involved in exit conference and audit plans |
| E4 | Human Resources Director | Interviewed regarding personnel records and audits |
| E19 | Registered Nurse (RN), Unit Manager (UM) | Interviewed regarding care plans and medication administration |
| E20 | Certified Nursing Assistant (CNA) | Observed providing care and interviewed regarding resident care |
| R3 | Resident | Subject of nail care deficiency |
| R46 | Resident | Subject of care plan and ear wax buildup deficiency |
| R51 | Resident | Subject of respiratory care deficiency |
| R40 | Resident | Subject of psychotropic medication monitoring deficiency |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 23, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide timely assistance with obtaining dental services for a resident who lost their dentures.
Findings
The facility failed to refer resident R45 for dental services within the required three-day timeframe after the resident reported lost dentures. The facility only scheduled a dental appointment nearly a month later, after the issue was escalated.
Complaint Details
The complaint investigation found that the facility did not act on the resident's report of lost dentures in May and only responded by scheduling a dental appointment on 6/22/23. The complaint was substantiated with findings reviewed during the exit conference on 6/23/23.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to provide assistance with obtaining dental services for resident R45 who lost dentures. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Days delayed: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director (ED) | Confirmed facility's response to lost dentures |
| E2 | Director of Nursing (DON) | Confirmed facility's response to lost dentures and scheduling dental appointment |
Inspection Report
Annual Inspection
Census: 58
Deficiencies: 1
Jun 23, 2023
Visit Reason
An unannounced annual and complaint survey was conducted at the facility from June 20, 2023 through June 23, 2023, including an Emergency Preparedness survey as required by 42 CFR 483.73.
Findings
The facility was found deficient in assisting residents in obtaining routine and 24-hour emergency dental care, specifically failing to promptly refer a resident with lost dentures for dental services within the required three days. No Emergency Preparedness deficiencies were found.
Deficiencies (1)
| Description |
|---|
| Failure to assist residents in obtaining routine and emergency dental care, including timely referral for lost dentures within three days. |
Report Facts
Facility census: 58
Sample size: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 (Executive Director) | Participated in exit conference and confirmed facility response to lost dentures | |
| E2 (Director of Nursing) | Participated in exit conference and confirmed facility response to lost dentures |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 8
Nov 19, 2021
Visit Reason
An unannounced complaint survey was conducted at the facility from November 4, 2021 through November 19, 2021 to investigate complaints and assess compliance with regulatory requirements.
Findings
The survey identified multiple deficiencies based on observations, interviews, and clinical record reviews, including failures in notification of changes, discharge planning, medication administration, nutrition, laboratory services, and medical record maintenance. The facility failed to notify the resident's Power of Attorney of significant medical changes, failed to provide required discharge notices, and lacked effective systems for medication and nutrition management.
Complaint Details
The visit was triggered by a complaint and was an unannounced complaint survey conducted from November 4, 2021 through November 19, 2021. The deficiencies were based on observations, interviews, and clinical record reviews. The facility census on the first day was 55 residents.
Deficiencies (8)
| Description |
|---|
| Failure to notify resident's Power of Attorney of significant medical changes. |
| Failure to provide Notice to Medicare Provider Non-Coverage (NOMNC) before terminating services. |
| Failure to provide comprehensive care plan goals and discharge summaries to receiving providers. |
| Failure to provide accurate discharge summaries and post-discharge plans of care. |
| Failure to maintain effective nutrition and hydration status maintenance. |
| Failure to provide routine medication administration and pharmacy consultation. |
| Failure to provide timely and adequate laboratory services. |
| Failure to maintain complete, accurate, and confidential medical records. |
Report Facts
Facility census: 55
Survey sample size: 4
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 11
Aug 13, 2021
Visit Reason
An unannounced annual and complaint survey was conducted at the facility beginning August 5, 2021 and ending August 13, 2021.
Findings
The report details multiple deficiencies based on observations, interviews, and review of residents' clinical records and other facility documentation. Deficiencies include emergency preparedness training, resident rights and grievance procedures, discharge planning, care plan revisions, pressure ulcer care, medication management, infection control, and abuse prevention training.
Complaint Details
The survey included complaint investigation components related to resident rights, grievance procedures, discharge planning, and abuse prevention training. Specific findings included residents unaware of the ombudsman program and grievance process, and staff lacking required abuse training.
Deficiencies (11)
| Description |
|---|
| Facility failed to provide emergency preparedness training at least annually to staff. |
| Facility failed to ensure residents were informed of the ombudsman program and their right to file a grievance/complaint. |
| Facility failed to provide safe and orderly discharge for one resident. |
| Facility failed to ensure care plans were revised to reflect residents' interventions. |
| Facility failed to provide appropriate care for pressure ulcers and off-loading of heels. |
| Facility failed to provide monthly drug regimen review for one resident. |
| Facility failed to store and maintain drugs and biologicals properly, including insulin pens. |
| Facility failed to maintain confidentiality and proper medical records. |
| Facility failed to conduct quality assessment and assurance committee meetings as required. |
| Facility failed to maintain infection prevention and control program and practices. |
| Facility failed to provide abuse, neglect, and exploitation training to staff. |
Report Facts
Facility census: 62
Investigative sample size: 22
Staff sample for emergency preparedness training: 15
Residents sampled for care plan review: 22
Residents sampled for abuse training review: 15
Meals reviewed: 543
Inspection Report
Complaint Investigation
Deficiencies: 12
Aug 10, 2021
Visit Reason
The inspection was conducted based on complaint investigation regarding failure to inform residents about the ombudsman program, care plan deficiencies, inadequate assistance with activities of daily living, failure to provide treatment according to orders, improper pressure ulcer care, medication regimen review issues, medication storage violations, food safety concerns, resident record inaccuracies, quality assurance meeting deficiencies, infection control lapses, and staff training deficiencies.
Findings
The facility was found deficient in multiple areas including failure to inform residents about the ombudsman program, incomplete and inaccurate care plans, inadequate assistance with activities of daily living, failure to follow physician orders for treatments and pressure ulcer care, lack of timely medication regimen review, improper medication storage, failure to monitor food temperatures, inaccurate resident records, failure to conduct required quality assurance meetings, lapses in infection control practices, and incomplete staff training on abuse and dementia care.
Complaint Details
The complaint investigation revealed multiple deficiencies including failure to inform residents about the ombudsman program, care plan inaccuracies, inadequate assistance with ADLs, failure to follow physician orders, medication regimen review issues, medication storage violations, food safety concerns, inaccurate resident records, quality assurance meeting deficiencies, infection control lapses, and incomplete staff training.
Severity Breakdown
Level of Harm - Potential for minimal harm: 1
Level of Harm - Minimal harm or potential for actual harm: 11
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to ensure residents were informed of the ombudsman including contact information and their right to file a grievance/complaint. | Level of Harm - Potential for minimal harm |
| Failed to revise care plans to reflect residents' interventions, including medication timing preferences and off loading for pressure ulcers. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide care and assistance to perform activities of daily living for a dependent resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide treatment according to physician orders and care plans, including dressing changes and foot treatments. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing by not off loading heels as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure monthly medication regimen review policies included time frames and failed to ensure physician review of pharmacist recommendations. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store and maintain drugs in accordance with professional principles by having undated insulin pens in medication carts. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to monitor food temperatures and ensure sanitary storage and preparation in accordance with professional standards. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure accuracy of resident records regarding dialysis injection schedules. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure the Quality Assessment and Assurance committee met at least quarterly with required members. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure proper infection control practices and hand hygiene during dressing changes and failed to apply protective caps to PICC line. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide required training on abuse, neglect, exploitation, and dementia care for some staff members. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents in investigative sample: 22
Meals reviewed for temperature logs: 543
QAPI meetings gap: 6
Staff training missing: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | NHA | Participated in exit conferences and confirmed findings |
| E2 | DON | Participated in exit conferences, provided interviews confirming deficiencies |
| E3 | Human Resources Director | Confirmed absence of required staff training |
| E5 | RN | Confirmed undated insulin pens and care plan deficiencies |
| E6 | RN | Interviewed regarding pressure ulcer off loading |
| E13 | Executive Chef | Confirmed food temperature monitoring deficiencies |
| E14 | Cook | Confirmed freezer condensation and ice formation |
| E16 | RN | Interviewed regarding unavailable foot cream treatment |
| E17 | RN, UM | Confirmed resident record discrepancy for dialysis injections |
| E18 | CNA | Observed failing to offload resident heels |
| E19 | LPN | Observed failing to perform hand hygiene during dressing changes |
| R3 | Resident with care plan and record discrepancies | |
| R9 | Resident with treatment and care deficiencies | |
| R39 | Resident with wound care and infection control deficiencies | |
| R50 | Resident with pressure ulcer care deficiencies | |
| R307 | Resident with inadequate assistance for ADLs |
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