Inspection Report Summary
The most recent inspection on February 26, 2025 identified multiple deficiencies related to nursing services, quality of care, accident prevention, and food service safety. Earlier inspections showed similar issues with care planning, staff training, and resident safety, including a substantiated complaint in 2019 involving inadequate assistance during resident transfers that caused injury. The main themes across reports involved nursing staff competencies, adherence to professional standards, and maintaining a safe environment for residents and staff. Complaint investigations were limited but included one substantiated case related to resident care and safety. The inspection history indicates ongoing challenges in meeting regulatory requirements, with no clear improvement trend over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
63% better than Delaware average
Delaware average: 8.8 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
31 residents
Based on a February 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 31
Deficiencies: 6
Feb 26, 2025
Visit Reason
An unannounced annual and complaint survey was conducted at the facility from February 20, 2025 through February 26, 2025 to assess compliance with professional standards and regulatory requirements.
Findings
The survey identified multiple deficiencies related to professional standards of quality, quality of care, accidents, nursing services, and food service safety. Deficiencies included failure to meet professional standards in admission assessments, inadequate fall risk evaluation and prevention, medication administration errors, and failure to maintain a safe food service environment.
Complaint Details
The inspection included complaint investigation as it was an unannounced annual and complaint survey. Specific complaint details are not separately stated but deficiencies related to medication administration and quality of care were identified.
Severity Breakdown
S/S = D: 4
S/S = G PNC: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility failed to meet professional standards of quality by having Licensed Practical Nurses complete admission assessments instead of Registered Nurses. | S/S = D |
| Facility failed to ensure quality of care by not providing treatment and care in accordance with professional standards and residents' choices. | S/S = D |
| Facility failed to ensure resident environment was free of accident hazards and provide adequate supervision to prevent accidents. | S/S = G PNC |
| Facility failed to ensure residents received care and services for bowel and bladder incontinence. | S/S = D |
| Facility failed to have sufficient nursing staff with appropriate competencies and skills to provide nursing and related services. | S/S = D |
| Facility failed to provide a safe working environment for food service staff and a vermin proof environment for food storage and preparation. | — |
Report Facts
Residents present: 31
Survey sample size: 6
Deficiency completion dates: Multiple deficiencies have completion dates ranging from 03/03/2025 to 04/24/2025
Medication administration delay: 7
Fall risk evaluation dates: Fall risk evaluation and incident dates from 11/1/24 to 11/8/24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Greenwalt | NHA | Named as Nursing Home Administrator signing multiple pages of the report |
| E12 | Nurse Practitioner | Documented assessments and medication orders related to resident SR7 |
| E14 | Licensed Practical Nurse | Completed admission assessments and documented progress notes for residents SR6 and SR7 |
| E10 | Licensed Practical Nurse | Involved in medication administration for resident SR7 |
| E6 | Registered Nurse | Interviewed regarding emergency medication supply and facility procedures |
| E1 | Nursing Home Administrator | Participated in exit conferences and review of findings |
| E2 | Director of Nursing | Participated in exit conferences and review of findings |
| E13 | Executive Director | Participated in exit conferences and review of findings |
| E3 | RNAC/Supervisor | Interviewed regarding facility's process for incontinent residents |
| E17 | Certified Nursing Assistant | Recalled resident SR6's confusion and incontinence |
| P1 | Pharmacy Clinical Case Manager | Interviewed regarding medication orders and pharmacy procedures |
| E8 | Director of Culinary | Interviewed during kitchen tour regarding food service deficiencies |
Inspection Report
Annual Inspection
Census: 31
Deficiencies: 3
Apr 26, 2022
Visit Reason
An unannounced annual and complaint survey was conducted at the facility from April 20, 2022 through April 26, 2022 to assess compliance with state and federal regulations.
Findings
The survey identified deficiencies related to comprehensive care plans, assisted nutrition and hydration, and abuse, neglect, and exploitation training. Specific findings included failure to revise care plans timely, inaccurate admission weights, lack of nutritional assessments, and incomplete staff training on abuse prevention.
Severity Breakdown
F 943: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to develop and revise comprehensive care plans within required timeframes and with appropriate interdisciplinary team involvement. | — |
| Failure to ensure accuracy of admission weight and proper documentation of nutritional interventions and assessments. | F 943 |
| Failure to provide required training on abuse, neglect, and exploitation to staff members. | F 943 |
Report Facts
Facility census: 31
Survey sample size: 15
Facility census: 89
Survey sample size: 5
Number of staff sampled: 12
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 1
Apr 15, 2019
Visit Reason
An unannounced complaint survey was conducted at the facility from April 11, 2019 through April 15, 2019 to investigate allegations related to resident care and safety.
Findings
The facility failed to provide adequate 2 person/staff physical assistance for one resident (R1) during transfers, resulting in a bruise on the resident's left elbow. The deficiency was linked to staff not following the plan of care and improper use of a standup lift.
Complaint Details
The complaint investigation found that resident R1 was dependent on 2 person/staff physical assistance for transfers but was transported with only one staff member using a standup lift, resulting in injury. The deficiency was substantiated based on interviews, record reviews, and observations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to provide 2 person/staff physical assistance for one resident during transfers, causing a bruise on the resident's left elbow. | SS=D |
Report Facts
Facility census: 44
Survey sample size: 3
Deficiency completion date: Jun 3, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E3 | Assistant Director of Nursing (ADON) | Interviewed regarding resident R1's care and transfer needs |
| E5 | Certified Nurse's Aide (CNA) | Interviewed and confirmed resident R1's transfer assistance |
| E1 | Nursing Home Administrator (NHA) | Confirmed findings with surveyor |
| E2 | Director of Nursing (DON) | Confirmed findings with surveyor and responsible for re-education and audits |
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