Deficiencies per Year
4
3
2
1
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 3
Dec 23, 2025
Visit Reason
An unannounced complaint survey was conducted at The Mary Campbell Center from December 22, 2025, through December 23, 2025, based on interview and review of clinical records and other facility documentation.
Findings
The facility failed to develop a final summary of the client's developmental, behavioral, social, health, and nutritional status at discharge for one of three residents reviewed. Additionally, the facility failed to provide a post-discharge plan of care to assist the client in adjusting to the new living environment and failed to provide a copy of the discharge summary release consent to the authorized representative.
Complaint Details
The complaint investigation found that one resident (R1) was affected by deficient practices related to discharge planning. The deficient practices were not immediately corrected because the resident was already discharged before the survey. The discharged resident's family was sent a Request for Medical Records but failed to return the signed form to the facility.
Deficiencies (3)
| Description |
|---|
| Failed to develop a final summary of the client's developmental, behavioral, social, health, and nutritional status at discharge for one resident. |
| Failed to provide a post-discharge plan of care that assists the client to adjust to the new living environment. |
| Failed to provide a copy of the discharge summary release consent to the authorized representative. |
Report Facts
Survey sample size: 3
Facility census: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tarah Pappas | Executive Director | Signed the report and plan of correction |
Inspection Report
Annual Inspection
Census: 67
Deficiencies: 1
Dec 5, 2024
Visit Reason
An unannounced annual, complaint, and emergency preparedness survey was conducted at the facility from December 2, 2024, through December 5, 2024.
Findings
The facility failed to thoroughly investigate four out of five allegations of neglect involving residents, with deficiencies identified in investigation procedures and documentation. No Emergency Preparedness deficiencies were found.
Complaint Details
The complaint investigation found that the facility did not thoroughly investigate allegations of neglect for four clients (C4, CS, C6, and C7). The investigation lacked interviews with key staff, incomplete documentation, and failure to provide needed personal care. The complaint was substantiated based on these findings.
Deficiencies (1)
| Description |
|---|
| The facility failed to thoroughly investigate allegations of neglect for four out of five sampled clients, including inadequate interviews, incomplete investigation reports, and failure to safeguard clients during and after investigations. |
Report Facts
Facility census: 67
Survey sample size: 11
Incident report number: 84704
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 1 | RN1 | Named in neglect investigation related to delayed brief change and communication issues |
| Resident Care Technician 1 | RCT1 | Named in neglect investigation related to brief changing and documentation failures |
| Resident Care Technician 2 | RCT2 | Named in neglect investigation related to failure to clean and change briefs properly |
| Executive Director | ED | Confirmed investigative packet completeness and participated in exit conference |
| Director of Nursing | DON | Participated in exit conference and oversight of investigation process |
Inspection Report
Recertification
Deficiencies: 1
Dec 21, 2023
Visit Reason
An unannounced on-site Recertification, Emergency Preparedness and Complaint Survey was conducted from 12/18/23 to 12/21/23 at the Mary Campbell Center ICF/IID facility.
Findings
The survey resulted in a finding of substantial compliance with no state deficiencies identified. One standard-level deficiency was cited related to nursing services documentation and wound assessment, with a corrective action plan developed to ensure compliance.
Complaint Details
The survey included a complaint investigation component and found substantial compliance with no immediate corrective action necessary. The resident's skin impairment was healed prior to the survey.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure one client was provided nursing services including measurements and description of injuries sustained during pool therapy. |
Report Facts
Survey dates: Survey conducted from 12/18/23 to 12/21/23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Interim Executive Director, NHA | Signed report | |
| Quality Assurance Performance Improvement/Registered Nurse (QAPI/RN) | Interviewed regarding documentation of client injuries | |
| Medical Director | Interviewed regarding expectations for wound measurement and documentation |
Inspection Report
Annual Inspection
Census: 68
Deficiencies: 3
Jan 30, 2020
Visit Reason
An unannounced annual and complaint survey was conducted at the facility from January 27, 2020 through January 30, 2020. The survey included an Emergency Preparedness Survey by the State of Delaware Division of Health Care Quality Long Term Care Residents Protection.
Findings
The facility was found to have deficiencies related to nursing services, including failure to prevent injury during resident transfer and failure to provide oral care immediately after eating. Additionally, infection control deficiencies were noted related to medication administration techniques. Corrective actions and training were implemented with follow-up audits planned.
Complaint Details
The survey included complaint investigation components as it was a combined annual and complaint survey. Specific substantiation status is not stated.
Deficiencies (3)
| Description |
|---|
| Failure to prevent injury to resident R5 during transfer due to improper seatbelt safety and release protocol. |
| Resident R1 did not receive oral care immediately after eating as ordered. |
| Failure to ensure proper infection control techniques during medication administration, including contamination of clean gloves and improper priming of insulin pens. |
Report Facts
Survey duration days: 4
Sample size: 12
Residents census: 68
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E8 | Resident Care Technician (RCT) | Staff member involved in resident transfer incident and seatbelt safety education |
| E9 | Resident Care Technician (RCT) | Witness to resident transfer incident |
| E5 | Licensed Practical Nurse (LPN) | Failed to avoid contaminating clean gloves during medication administration |
| E6 | Licensed Practical Nurse (LPN) | Failed to maintain aseptic technique and properly prime insulin pen |
| E7 | Licensed Practical Nurse (LPN) | Failed to avoid contaminating clean gloves during medication administration |
| E3 | Staff Educator | Provided training on seatbelt safety and infection control procedures |
| E12 | Resident Care Technician (RCT) | Observed feeding and oral care procedures for resident R1 |
| E13 | Speech Language Pathologist (SLP) | Provided assessment and recommendations for resident R1's oral care |
| E10 | Resident Care Technician (RCT) | Interviewed regarding sling of lift use during resident transfer |
| E11 | Resident Care Technician (RCT) | Interviewed regarding sling of lift use during resident transfer |
| E14 | Physical Therapist (PT) | Provided statement regarding resident transfer and seatbelt use |
| E1 | Assistant Executive Director (AED) | Participated in exit meeting and review of findings |
| E2 | Director of Nursing (DON) | Participated in exit meeting and review of findings |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 2
Jul 31, 2019
Visit Reason
An unannounced complaint survey was conducted at the Mary Campbell Center from July 30, 2019 through July 31, 2019 based on observation, interview, and review of clients' records and other facility documentation.
Findings
The facility failed to develop and implement written policies and procedures prohibiting mistreatment, neglect, or abuse of clients. Specifically, the facility did not immediately report an allegation of neglect related to a resident's fall and use of improper sling size, which resulted in a left parietal scalp hematoma. Staff education and policy revisions were planned to address these issues.
Complaint Details
The complaint investigation found that one resident experienced a fall due to staff using the wrong size sling during transfer, resulting in a left parietal scalp hematoma. The facility failed to immediately report the allegation of neglect. The allegation was not substantiated as neglect after investigation.
Deficiencies (2)
| Description |
|---|
| The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of the client. |
| The facility failed to immediately report an allegation of neglect related to a resident's fall caused by use of the wrong sling size during transfer. |
Report Facts
Facility census: 48
Survey sample: 3
Sub-sampled residents: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Director of Nursing (DON) | Involved in education and investigation of the neglect allegation and fall incident |
| E6 | Resident Care Technician (RCT) | Notified nurse after resident fall and involved in transfer incident |
| E7 | Resident Care Technician (RCT) | Involved in transfer incident and interviewed during investigation |
| E1 | Assistant Executive Director (AED) | Participated in exit meeting and received incident reports |
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