Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Brackenville Llc during CMS and state inspections, most recent first.
The facility failed to thoroughly investigate several allegations of verbal and potential physical abuse involving four cognitively intact residents with conditions including hemiplegia, rheumatoid arthritis, type 2 DM, epilepsy, and heart disease. In each case, the facility’s investigations were limited, often including only the directly involved resident and omitting interviews with other potentially knowledgeable residents or staff. One resident reported a verbal altercation with a CNA after a fall to the floor, another reported being verbally abused by a roommate’s family member, a third reported a male CNA was too rough and upset while changing linens, and a fourth reported a staff member insulted her and refused brief care. Investigation files lacked broader resident and staff interviews, timely physical and psychosocial assessments, and review of the accused staff member’s employee record, contrary to the facility’s abuse policy requiring identification and interviews of all involved persons and others who might have knowledge of the allegations.
A resident with multiple diagnoses, including ocular myasthenia gravis, repeatedly refused prescribed pyridostigmine bromide tablets. Despite the resident being cognitively intact and refusing medication on numerous occasions, there was no care plan in place to address these refusals, as confirmed by record review and staff interviews.
A resident with a leg infection and pressure ulcer received IV daptomycin at an incorrect dose and with mislabeled medication bags after pharmacy delivery errors. Nursing staff administered the medication without verifying the correct dosage or patient identifiers, and the facility did not fully investigate how many incorrect doses were given or which nurses were involved.
A resident with a leg infection and pressure ulcer was administered intravenous daptomycin at a higher dose than ordered after pharmacy-delivered medication bags intended for another patient were relabeled and used by nursing staff. The error was not immediately identified, resulting in the resident receiving incorrect doses on multiple occasions.
The facility failed to address grievances from the resident council over several months, including issues with laundry and maintenance. The Activity Director was unfamiliar with grievance procedures, and the Administrator, who was the grievance officer, did not ensure grievances were resolved or communicated back to residents. The Regional Operations Manager was unaware of the Administrator's role in the meetings and emphasized the need for proper documentation and response to grievances.
A resident's call light went unanswered for 38 minutes, despite staff presence nearby, highlighting a failure in the facility's response system. The resident, who was cognitively intact and dependent on staff for daily activities, expressed frustration over the delay. The facility's policy requires all staff to respond to call lights, but this was not adhered to, as confirmed by interviews with the LPN, RN, and DON.
A facility failed to assess a resident's ability to self-administer medications, resulting in medications being left unattended. The resident, who was cognitively intact, was observed with medications on her overbed table without a documented assessment or care plan. An LPN confirmed the resident preferred to take her own medications, but was unsure if an assessment was conducted. The DON stated the nurse should have stayed until the resident took all her medications.
The facility failed to document the accurate code status for two residents, leading to a deficiency in respecting their treatment preferences. Both residents had a Full Code status in the EMR without supporting documentation of their decisions. The Administrator admitted responsibility for acquiring advance directives but had not obtained them for these residents, resulting in a default Full Code status. The facility's policy was not provided during the survey.
A facility failed to attempt alternative measures before installing side rails for a resident with severe cognitive impairment. The resident, who was legally blind and had gout, required assistance with bed mobility. Despite the facility's policy to explore alternatives, no such measures were attempted. Interviews with staff revealed a lack of awareness and adherence to the policy, leading to the deficiency in ensuring resident safety.
Incomplete Investigations of Multiple Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate multiple allegations of verbal or potential physical abuse as required by its abuse, neglect, and exploitation policy. One cognitively intact resident with hemiplegia following a stroke reported a verbal altercation with a CNA after sliding to the floor while being assisted back to bed. The resident requested use of a Hoyer lift, the CNA told him he could get himself up, and an argument ensued in which the CNA told the resident it was not his room and did not leave until directed by an LPN. The facility’s investigation file for this incident contained only the resident’s interview and no interviews with other residents on the unit who might have had knowledge of similar verbal abuse by the CNA. Another cognitively intact resident with rheumatoid arthritis, hypertension, and peripheral vascular disease reported that her roommate’s daughter came into her room and verbally abused her after the roommate had been relocated due to aggression. The daughter allegedly cursed at the resident, calling her an offensive name and telling her she was going to hell. The investigation file for this incident contained no interviews with other residents on the unit to determine whether they had experienced verbal abuse by this family member or had knowledge of the event. The DON acknowledged that no such interviews were conducted. A third cognitively intact resident with type 2 diabetes and epilepsy reported, through her daughter, that a male CNA wearing a red shirt was too rough with her and appeared upset about having to change her linens. The facility’s investigation into this potential staff-to-resident abuse included an interview with the resident but did not include interviews with other interviewable residents in the same area who might have had knowledge of the incident. A fourth cognitively intact resident with type 2 diabetes and heart disease, later discharged, reported that a staff member entered her room, called her a poor excuse for a human being, and refused to assist with changing her brief. The investigation documentation for this allegation lacked interviews with additional residents or staff, did not show that the resident was promptly assessed physically and psychosocially in relation to the allegation, and did not include a review of the accused staff member’s employee record, resulting in an incomplete investigation contrary to facility policy requiring identification and interviews of all involved persons and others who might have knowledge of the allegations.
Failure to Develop Care Plan for Medication Refusal
Penalty
Summary
A deficiency was identified when the facility failed to develop a person-centered care plan addressing a resident's repeated refusal of prescribed medications. The resident, who was admitted with diagnoses including muscle weakness, bladder cancer, and ocular myasthenia gravis, was prescribed pyridostigmine bromide tablets twice daily. Despite being cognitively intact, as indicated by a BIMS score of 15, the resident refused this medication on twenty-eight occasions out of forty-nine opportunities over a period of several weeks. Review of the clinical records revealed no evidence of a care plan to address these medication refusals. This finding was confirmed through interviews with facility staff, including the DON, and was discussed during the exit conference.
Failure to Administer IV Medication per Physician Order and Standards
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including a right lower leg infection and a pressure ulcer, was not administered intravenous daptomycin according to the physician's order. The resident was ordered to receive 800 mg of daptomycin IV daily, but nurses administered 850 mg IV daily using medication bags that were incorrectly labeled with another patient's identifiers. The error was discovered after the pharmacy notified the facility that medication intended for another patient at a different facility had been delivered in error. Nurses had crossed out the original name on the IV bags and relabeled them with the resident's name without verifying the correct dosage or patient information. The facility failed to thoroughly investigate the medication error, as it was unclear exactly how many incorrect doses were administered and which nurses were involved. Documentation showed that at least one incorrect dose was given, and two remaining bags were removed from the fridge after the error was identified. Interviews revealed that staff did not consistently check medication labels or dosages before administration, and the process for accepting and verifying pharmacy deliveries was not adequately followed. The facility did not ensure that the resident's IV medication was administered according to accepted standards of clinical practice.
Failure to Administer Medication per Physician's Order Due to Pharmacy and Nursing Errors
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including a right lower leg infection and a pressure ulcer, was not administered medication according to the physician's order. The resident was prescribed 800 mg of intravenous daptomycin daily, but received 850 mg for two or three doses. The error was traced to the delivery of medication bags from the pharmacy that were intended for another patient at a different facility. The incorrect bags were labeled with another patient's name, which was crossed out and replaced with the resident's name by nursing staff. The medication administration record confirmed that the higher dose was given on at least two occasions. Interviews with nursing staff and the DON revealed that multiple nurses were involved in administering the incorrect medication. One nurse admitted to changing the label on the IV bag and did not realize the dosage discrepancy until later. The facility's investigation indicated that the error was discovered after the pharmacy and another facility reported the delivery mistake. Documentation showed that the medication error was not immediately identified, and the incorrect medication was administered despite the mismatch between the physician's order and the medication label.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to promptly address grievances and recommendations from the resident council group over a period of seven out of twelve months. During a group meeting, residents reported that their concerns were repeatedly brought up in monthly meetings without receiving explanations or resolutions. Specific grievances included issues with laundry, such as towels smelling bad and having stains, and clothing not being properly hung up. Additionally, residents complained about a leaking toilet, a slamming kitchen door, and a broken TV in the dining room, none of which were documented as resolved. The Activity Director, who had been in the role for about five weeks, was unfamiliar with the rules and regulations regarding resident council meetings and grievance handling. She noted that the Administrator took over the meetings and that she was not clear on who was responsible for following up on the residents' concerns. The Administrator, who served as the grievance officer, admitted to documenting grievances but did not follow up to ensure they were resolved or communicated back to the residents. The Regional Operations Manager was unaware that the Administrator had been facilitating the resident council meetings for the past eleven months. She stated that staff should only attend these meetings if invited and that grievances should be documented and addressed with a written response within three days. The facility's policy on grievances emphasized the residents' right to voice grievances without fear and required the Administrator to oversee the grievance process, including issuing written decisions and keeping residents informed of progress toward resolution.
Failure to Respond Timely to Call Lights
Penalty
Summary
The facility failed to ensure timely response to call lights, as observed in the case of a resident who was cognitively intact and dependent on staff for toileting, bathing, and dressing. During a continuous observation, the resident's call light remained on for 38 minutes without being answered. During this period, various staff members, including an LPN, CNAs, the Activities Director, and housekeepers, were present in the vicinity but did not respond to the call light. The LPN acknowledged that call lights should be answered in less than five minutes and that all staff should respond to call lights, even if they cannot directly assist the resident. The resident expressed frustration over the delay, stating that it was common to wait for call lights to be answered and that she almost fell while trying to plug in her phone. The facility's policy mandates that all staff members respond to activated call lights and notify appropriate personnel if they cannot fulfill the resident's request. Interviews with the RN and DON confirmed that all staff are responsible for answering call lights to prevent potential emergencies, highlighting a systemic issue in the facility's response to resident needs.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident's ability to self-administer medications, leading to an unsafe environment. The resident, who was cognitively intact with a BIMS score of 15 out of 15, was observed with medications left unattended on her overbed table. The facility's policy requires an interdisciplinary team assessment and a care plan for residents to self-administer medications safely, but no such assessment or care plan was documented for this resident. During an observation, an LPN was seen leaving the resident's room with medications left on the overbed table. The resident was able to identify each pill and stated that most nurses left her medications for her to take, except for agency nurses who waited until she took them. The LPN confirmed that the resident liked to take her own medications but was unsure if an assessment or care plan was in place. The DON acknowledged that the nurse should have stayed until the resident took all her medications and confirmed that the resident did not keep medications in her room.
Failure to Document Accurate Code Status for Residents
Penalty
Summary
The facility failed to ensure that the accurate code status was documented and available for reference for two residents, leading to a deficiency in honoring residents' rights to have their treatment preferences respected. Resident 49, who was moderately cognitively impaired, and Resident 38, who was severely cognitively impaired, both had a documented code status of Full Code in the electronic medical record (EMR). However, there was no documentation to support these residents' decisions regarding their code status, as required by their advance directives. The Administrator acknowledged responsibility for acquiring advance directives and admitted that the facility had been cited previously for similar issues. Despite a plan to educate and ask residents with a BIMS score of 13 or higher about their advance directives, the Administrator had not obtained the necessary documentation from the families of the two residents in question. As a result, the default code status of Full Code was applied, meaning CPR would be administered in an emergency without the proper documentation of the residents' wishes. The facility's policy on this matter was not provided during the survey.
Failure to Attempt Alternatives Before Bed Rail Use
Penalty
Summary
The facility failed to ensure that alternative measures were attempted before the installation of side rails for a resident with severe cognitive impairment. The resident, who was legally blind and had gout, was readmitted to the facility and required assistance with activities of daily living, including bed mobility. The care plan indicated the use of side rails for safety and assistance with bed mobility, but the bed rail evaluation revealed that no alternatives were attempted prior to their installation. The facility's policy required a person-centered approach and the exploration of alternative measures before using bed rails, which was not followed in this case. Interviews with facility staff, including the Director of Rehab, Assistant Director of Nursing, and Director of Nursing, revealed a lack of awareness and adherence to the policy regarding bed rail use. The Director of Rehab stated that therapy did not assess the resident for bed rail needs, while the Assistant Director of Nursing was unsure of the frequency of bed rail assessments and what alternatives were attempted. The Director of Nursing believed it was the resident's right to have bed rails if requested, without knowledge of the regulation requiring alternatives to be explored first. This oversight led to the deficiency in ensuring resident safety and compliance with facility policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hockessin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pike Creek Nursing & Rehabilitation Center | 1.3 mi | ★★★★★ | 6 | 0 |
| Willowbrooke Court At Cokesbury Village | 2.2 mi | ★★★★★ | 0 | 0 |
| Regal Heights Healthcare & Rehab Center | 2.7 mi | ★★★★★ | 3 | 0 |
| Cadia Rehabilitation Pike Creek | 3.1 mi | ★★★★★ | 3 | 0 |
| Coral Springs Rehab & Healthcare | 4.2 mi | ★★★★★ | 8 | 0 |
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