Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Excelcare At Lewes Llc during CMS and state inspections, most recent first.
A resident with dementia, Parkinson’s disease, CHF, and a history of AKI had documented fluid goals and was identified as at risk for dehydration and malnutrition, yet daily intake records repeatedly showed fluid consumption well below the recommended amounts. Despite severely impaired cognition, poor oral intake, and documented changes in mentation, lethargy, falls, and restlessness, the facility did not consistently implement or document enhanced monitoring, assistive feeding measures, or timely provider consultation focused on hydration. The resident was hospitalized twice with AKI, dehydration, hypotension, and anemia, and staff interviews confirmed that while expectations existed to encourage fluids and notify providers when goals were not met, there was no clear evidence that these expectations were carried out for this resident.
A resident with cardiac conditions was discharged home with a documented post-discharge plan for home health aide, home health RN/LPN, and PT/OT, but the facility did not complete the home health referral before discharge. The resident went home with a family member and, according to a complaint, did not receive PT, OT, or a nursing wellness check for about a week. The SW later confirmed the referral for home health and therapy services was not requested until several days after discharge, and services did not begin until even later, despite therapy recommendations that are typically communicated to social services to arrange home care.
The facility failed to consistently revise care plans to reflect residents’ current needs and behaviors and did not ensure a cognitively intact resident was involved in ongoing care planning. One resident participated in an initial care conference but was not included in later care plan updates. Another resident with an order for a palm protector was frequently observed without it and often refused it, yet the care plan did not address refusals. Two cognitively impaired residents whose MDS assessments showed dependence for bathing had care plans that still listed only setup or one‑person assist. A cognitively impaired resident with combative behaviors and an incident of striking another resident had a behavior care plan that was not updated to include attempts to hit other residents or the risk of resident‑to‑resident altercations.
A resident with a neurogenic bladder and chronic Foley catheter experienced repeated catheter-related problems, including difficult reinsertion, multiple dislodgements, frequent leakage, and episodes of bleeding with clots that led to hospital evaluation. Imaging showed the catheter balloon positioned in the penile urethra. LPNs reported ongoing difficulty changing the catheter and indicated that the resident had been recommended for urology follow-up and catheter changes by urology due to the complexity. Despite an expectation to schedule outside providers promptly, the resident was not seen by urology until many months after these ongoing catheter issues, resulting in a deficiency for failure to obtain a timely urology referral.
A resident with an order for dialysis three times weekly was sent to dialysis and refused treatment, then returned to the facility without interventions. An LPN said the dialysis center called to report the resident did not receive dialysis, but no progress note was written; the UM was unaware the resident missed dialysis, and the NP stated she was not notified even though she expected to be.
A resident’s family reported missing top dentures, and the grievance was documented, forwarded to the SW, and discussed with the family. However, the record showed no documented investigative findings, corrective actions, or grievance closure for months, and staff later confirmed the facility could have obtained dental services on a fee-for-service basis instead of waiting on Medicaid eligibility. The denture replacement was not resolved until about eight months after the grievance began.
PRN Lorazepam Extended Without Required Rationale or Duration: A resident with dementia, psychotic disturbance, mood disturbance, and anxiety received repeated PRN lorazepam orders for anxiety/agitation that were extended beyond the 14-day limit without documented rationale or duration. MRRs noted the need for a specified duration and stated there was no hospice exception, while staff interviews confirmed the record lacked the required documentation and that the medication was reordered as indefinite.
Inaccurate MDS coding was identified for three residents when assessments documented an infection of the foot. The MDS Coordinators confirmed the coding was based on a fungal infection documented by the podiatrist for each resident. The findings were reviewed with the NHA, ROD, and DON at exit conference.
Failure to Provide ADL Nail Care: A resident with a stroke affecting the right side was documented as dependent on staff for bathing, dressing, and ADL care, but observations showed long fingernails and black debris under the fingernails of the right hand. The care plan did not include a refusal of nail care, and staff interviews confirmed that bathing included nail care, yet the resident’s nails remained unaddressed.
Respiratory Equipment Not Stored Properly: A resident with COPD and chronic respiratory failure had oxygen tubing and a nebulizer face mask observed outside of a protective plastic bag when not in use. The resident’s record included an order to place the nebulizer face mask in a plastic bag after use, but the TAR lacked evidence of an order for storing the mask and tubing in a protective bag. An LPN confirmed the equipment should be stored in a protective plastic bag when not in use.
Failure to Provide Ordered Pain Medication: A resident with cervical spondylopathy, muscle weakness, and chronic pain syndrome did not receive ordered oxycodone when requested for significant neck pain. The MAR showed the medication was not given, the resident reported being told the medication was not available, and the RN later confirmed the order had expired and no new order was obtained to use back-up pain medication.
Failure to Complete Dialysis Catheter and Pre/Post Dialysis Assessments: A resident receiving HD for renal failure had a care plan and physician order for scheduled dialysis, but the record lacked an order to assess the dialysis catheter and lacked documentation of pre- and post-dialysis assessments. An LPN and the UM confirmed the expectation for nursing staff to complete and document these assessments, including catheter assessment, but the progress notes did not show they were done.
Failure to Ensure Provider Review of MRR Irregularities: The facility did not ensure that irregularities identified during monthly pharmacist MRRs were reviewed by the attending provider or designee. For one resident with hypothyroidism, a charting omission for levothyroxine was noted without an attending signature. For two other residents, multiple MRRs identified irregularities, but the reviews lacked evidence of provider review and were instead signed by nursing staff or the ADON. The NP and ADON confirmed that providers did not review all MRRs with documented irregularities.
A resident’s drug regimen was not free from unnecessary medication when Metoprolol for HTN was ordered with hold parameters, but the dose was held repeatedly over several months due to low BP or low HR. The NP later confirmed the medication was no longer appropriate because of low BP and stated she had not been informed how often the doses were being held.
A resident received metoprolol multiple times even when SBP or HR were below the physician’s hold parameters. Record review showed repeated administrations outside ordered limits across several months, and an MRR irregularity report documented that the medication was not always held as required. An LPN confirmed giving the medication if only one vital sign was within range, and the NP confirmed the order required holding the dose for either parameter.
Delayed Replacement of Lost Dentures: A resident’s top dentures were reported missing, and although staff completed room sweeps and notified the DON, the facility did not promptly initiate replacement within the required timeframe. The grievance notes showed the delay was tied to a meeting about Medicaid eligibility, even though the BOM confirmed fee-for-service dental care could have been used without waiting for that determination.
The facility failed to assist two residents with obtaining routine dental services. One resident was cognitively intact, had broken and missing teeth, and stated he had requested extractions since admission but had not seen a dentist; staff confirmed he was not enrolled in the dental program and had no dental appt. Another resident had a care plan for broken carious teeth and poor oral hygiene, with the record showing a dental exam, but the deficiency cited the facility for failing to assist both residents with routine dental care.
Improper Dating of Opened Thickened Water in Nutrition Refrigerators: The facility failed to ensure opened cartons of thickened water were dated correctly in nutrition refrigerators. Surveyors found three opened cartons in one nutrition refrigerator and one carton in another that were incorrectly dated, despite manufacturer instructions stating remaining product should be discarded after four days.
The facility failed to ensure the Medical Director oversaw implementation of the Drug Regimen Review policy consistent with professional standards for provider documentation of identified irregularities. The policy required the attending physician to document review of the irregularity and any action taken, but the ROD confirmed the Medical Director was not ensuring provider compliance and stated the DON was reviewing the irregularities and notifying the provider instead.
Inaccurate fall documentation was identified when a resident’s incident report stated no injuries were observed, even though a progress note documented a forehead hematoma after the resident was found face down on the floor in the dining area. A staff member confirmed the discrepancy and stated the injury had been entered in another section of the report.
The facility failed to maintain a homelike environment by routinely using an overhead paging system for non-emergent staff communication during daytime hours. Surveyors repeatedly heard overhead pages during observations, and a resident reported during a council meeting that the paging was unpleasant. The NHA confirmed that overhead paging was used to communicate with staff during the day and discontinued only in the evening, contributing to an environment that residents found uncomfortable.
Two residents with severe cognitive impairment experienced escalating verbal and physical conflict over several weeks, with one resident exhibiting increasing aggression and behavioral disturbances. Despite repeated documentation of these behaviors and ongoing roommate conflict, the facility did not revise care plans, increase supervision, or notify the social worker. The situation culminated in a physical altercation where one resident sustained a head injury and required hospital evaluation.
Two incidents of suspected abuse involving residents were not reported to the State Agency within the required two-hour timeframe. In one case, a resident had a psychotic episode and made physical contact with others, but the report was delayed to ensure accuracy. In another case, a resident alleged being choked by her spouse, but the allegation was not promptly communicated to management or reported as required.
A resident's clinical record lacked required documentation following an incident, including progress notes and consults. Although electronic communication suggested a wellness check occurred, an LPN confirmed that the resident was not seen by a psychiatrist and that no relevant notes were present in the medical record. This deficiency was confirmed through staff interviews and record review.
A resident with chronic health conditions and full cognitive function was left in a room with soiled, odorous bed linens while being served breakfast. Despite requests, staff delayed changing the linens, prioritizing meal tray distribution. Nursing leadership later confirmed that linens should have been changed before the meal was provided, resulting in a failure to ensure a dignified dining experience.
A staff member engaged in a verbal altercation with a cognitively intact resident, using an argumentative tone and profanity, in violation of facility policy prohibiting verbal abuse. The incident was witnessed by a social worker and reported by staff, with varying recollections of the details.
An LPN was found to have taken a resident's prescribed Percocet from the medication cart, resulting in the misappropriation of the medication. The incident was discovered after a medication count discrepancy and confirmed through pharmacy records and facility investigation. The resident had an active order for Percocet for pain management, and the LPN did not respond to contact attempts after leaving the facility.
A resident with moderate cognitive impairment expressed fear of a staff member, but the allegation was not reported to the Abuse Coordinator or State Survey Agency as required by facility policy. The ADON and DON did not initiate an investigation, citing the resident's confusion, and the Administrator later confirmed the report should have been made regardless of cognitive status.
A resident with moderate cognitive impairment reported fear of a staff member to the ADON, but no investigation was conducted due to assumptions about the resident's confusion. The DON and ADON did not report or investigate the allegation, and the administrator later confirmed that the incident should have been reported and investigated according to facility policy.
A resident with bilateral above-knee amputations and diabetes did not receive wound care as ordered, with a scheduled dressing change missed and the care plan not updated to reflect new wound care orders. Nursing staff and leadership confirmed the lapse after reviewing the medical record and physician orders.
A resident with dementia and diabetes, who developed a stage 2 pressure sore and a deep tissue injury, did not receive a low air loss mattress as ordered by the wound care physician. Despite multiple observations and confirmation from the UM and ADON, the mattress was not applied, and the resident remained on a regular pressure reducing mattress, resulting in incomplete implementation of pressure ulcer care interventions.
Two residents sustained injuries during incontinence care when staff failed to follow care plans requiring two-person assistance and use of a mechanical lift. One resident, dependent for all ADLs, rolled off the bed and suffered a forehead laceration when left with only one CNA. Another non-ambulatory resident was assisted to stand without a lift, resulting in a skin tear and requiring multiple staff to return her to bed. Staff interviews and records confirmed care protocols were not followed.
Two residents with indwelling urinary catheters did not have appropriate physician orders or documentation for routine catheter care. One resident with quadriplegia and urinary retention had no orders or evidence of catheter care in the EMR, MAR, or TAR, despite a care plan indicating scheduled changes. Another resident with acute kidney failure and bladder dysfunction also lacked catheter care orders and reported the catheter was overdue for a change. The ADON confirmed missing orders and stated that catheter changes were only done when symptomatic, with some orders not transferring from the hospital.
A resident with quadriplegia was found with side rails raised on both sides of the bed without a physician's order, care plan documentation, or evidence that alternatives were considered. The resident was unable to use the side rails, and staff confirmed that proper assessment and authorization were not completed prior to their use.
A nurse administered Ativan and morphine to a resident without a physician's order, failing to verify the resident's identity before giving the medications. The resident, who had heart failure, anemia, and COPD, did not have these medications ordered, and the error was discovered immediately after administration.
The facility did not ensure proper PPE use for a resident on contact isolation with a PEG tube, as an LPN administered medications without donning a gown as required by policy. Additionally, another resident experiencing multiple episodes of vomiting was not promptly identified or placed on contact isolation after developing COVID-19, and staff failed to communicate the resident's symptoms to nursing leadership in a timely manner.
The facility failed to ensure that referrals for PASARR screenings were completed for five residents who had changes in their mental health conditions or new psychiatric diagnoses. These failures were confirmed through interviews with facility staff and email correspondence with the State PASARR Authority, which indicated that the facility should have submitted resident review PASARRs for these cases. The findings were reviewed with the facility's nursing home administrator, director of nursing, assistant director of nursing, and corporate representatives during the exit conference.
A resident with specific dietary needs was served whole cauliflower florets instead of the prescribed ground cauliflower. The resident, who does not use dentures and has no natural teeth, found the food too hard to consume. Staff confirmed the discrepancy between the meal ticket and the food served.
The facility failed to provide a clean and homelike environment for a resident, with observations revealing dirt, food crumbs, black debris, and a peeling baseboard in the room. Despite the resident reporting these issues to maintenance a year ago, the room remained unclean, and the baseboard was not fixed until later.
The facility failed to ensure that a physician reviewed the total program of care, including medications and treatments, for a resident admitted with an indwelling urinary catheter. The physician's progress note lacked mention of the catheter, resulting in six days without proper orders. This was confirmed by a nurse practitioner and discussed with facility leadership during the exit conference.
The facility failed to ensure a qualified person was present in the kitchen during all hours of food service operation. Only one staff member had a valid Food Protection Manager certificate. These findings were reviewed with the NHA, DON, ADON, and a corporate representative during the exit conference.
The facility failed to ensure proper food storage, preparation, and sanitization. Observations included uncovered food, unlabeled and undated items, and insufficient sanitizer levels, which were confirmed by the NHA and reviewed with the DON, ADON, and a corporate representative.
The facility failed to ensure that the call bell system in a resident's room was functioning properly. The call bell box was taken apart with exposed wires, and no alternate equipment was available for the residents to call for help. An RN confirmed the issue, and the Maintenance Director stated that a work order had been submitted four days prior but could not be addressed sooner. The call bell system was eventually repaired and tested.
A resident with severe cognitive impairment was found with a bruise of unknown origin on the left upper arm. The facility did not document measurements or descriptions, failed to report the incident to the state agency within the required timeframe, and did not notify the resident's family. This was confirmed by the DON and other staff members.
The facility failed to ensure that a resident had physician orders for immediate care upon admission. The resident was admitted with an indwelling urinary catheter and diabetes, but the necessary physician orders for both conditions were not obtained until several days later. Staff interviews confirmed that the admitting nurse forgot to obtain the batch orders from the provider.
The facility failed to ensure that a resident with chronic idiopathic constipation received treatment and care according to physician orders. From 7/1/23 through 9/30/23, the facility did not implement the bowel protocol when the resident failed to have bowel movements for nine shifts on multiple occasions. The necessary medications were not administered, and there was a lack of monitoring and bowel assessments. These findings were confirmed by an RN and reviewed with facility leadership during the exit conference.
Failure to Maintain Adequate Hydration Resulting in Recurrent AKI and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate hydration for a resident with significant medical conditions, including acute kidney injury (AKI), congestive heart failure (CHF), dementia, and Parkinson’s disease. Upon admission, the resident’s care plan identified potential for altered nutrition and included interventions such as assisting at meals, encouraging oral fluids, and monitoring for additional nutrition interventions. A nutrition assessment established an initial fluid goal of 1943–2098 mL/day and documented that the resident was at risk for dehydration and malnutrition, with early labs showing a BUN of 29, creatinine of 1.4, and eGFR of 53. The admission MDS documented that the resident was severely cognitively impaired and required setup assistance for feeding and hydration. Daily fluid intake records from CNA task flow sheets and the MAR showed that the resident’s intake frequently fell below the recommended fluid goals, with multiple days of intake under 1200 mL and some days as low as 360–720 mL. A malnutrition risk assessment identified the resident as at risk for malnutrition due to severe dementia and tremors. A subsequent nutrition note on 5/12/25 documented that the resident’s average fluid intake was 330 mL/day, recommended discontinuing a prescribed hydration pass due to CHF, and set a new fluid goal of 1635–1766 mL/day, while continuing to recommend encouraging oral fluids. Despite these documented risks and low intakes, there is no evidence in the record of intensified monitoring or additional interventions to ensure the resident met the revised fluid goals. The resident experienced multiple clinical deteriorations associated with poor intake and changes in condition. On 6/1/25, after a day with only 360 mL of recorded intake, the resident was transferred to the hospital following falls, hypotension, and confusion, and was admitted with AKI and dehydration. After readmission to the facility, nursing documentation noted low oral intake and a plan to discuss adding the resident to an assist-to-feeding list, but the record lacked evidence that this occurred. Subsequent notes documented lethargy, increased confusion, agitation, restlessness, and continued poor intake, yet a physician progress note following two unwitnessed falls did not include an assessment of hydration status or interventions to improve hydration. On 6/19/25, labs showed a BUN of 62 mg/dL and creatinine of 1.7 mg/dL, and the resident was again sent to the hospital and admitted with AKI, hypotension, and anemia, requiring IV fluid resuscitation. Staff interviews confirmed expectations to monitor intake, encourage fluids, and notify providers when fluid goals were not met, but there was no documentation that the provider was consistently notified or that appropriate interventions were implemented in response to the resident’s ongoing inadequate fluid intake and changes in condition.
Failure to Arrange Timely Home Health Services Prior to Discharge
Penalty
Summary
The facility failed to ensure a timely referral for home health care services prior to discharge for one resident. Facility policy dated 5/1/25 required sufficient preparation and orientation to residents to ensure an orderly transfer or discharge. The resident was admitted on 7/28/25 with diagnoses including aortic valve replacement, aortic regurgitation, and congestive heart failure. A discharge summary dated 8/11/25 documented a post-discharge plan for home health aide, home health RN/LPN, and occupational and physical therapy. The resident was discharged home with a family member on 8/12/25. A complaint received by the Division on 9/30/25 stated that the resident was discharged to a family member's home without a home health care agency referral and that, after one week at home, the resident had not received any physical or occupational therapy or a wellness check from a nurse. During an interview on 2/16/26, the social worker reported needing to check if a referral was made and later confirmed that the referral for home health and therapy services was not requested until 8/15/25, with services opened on 8/20/25. The director of therapy confirmed that physical and occupational therapy were recommended for the resident and stated that such recommendations are typically communicated to social services to set up home care. Findings were reviewed with facility leadership during the exit conference.
Failure to Revise Care Plans and Involve Resident in Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to develop and revise person‑centered care plans and to involve a cognitively intact resident and/or representative in the care planning process. One resident with an intact BIMS score of 15 was admitted and had a documented care conference shortly after admission, but there was no evidence of any subsequent care conferences during the following year despite multiple care plan updates. The resident reported not recalling quarterly care plan meetings, and staff confirmed that no care conferences occurred after the initial one, with no documentation that the resident or representative participated in the later care plan revisions. Additional residents’ care plans were not revised to reflect current, individualized needs and behaviors. One resident had a physician’s order for a right palm protector or substitute, was repeatedly observed without it in place, and routinely refused it according to nursing and CNA interviews, yet the care plan did not address potential refusals. Two cognitively impaired residents whose MDS assessments documented dependence for bathing had care plans that continued to list only setup assistance or one‑person assist, without updating to reflect full dependence. Another cognitively impaired resident with documented combative behaviors toward staff and a reported incident of striking another resident with a remote had a behavior care plan that was not revised to include the new behavior of attempting to hit other residents or the potential for resident‑to‑resident altercations.
Failure to Obtain Timely Urology Referral for Resident With Ongoing Foley Catheter Issues
Penalty
Summary
The deficiency involves the facility’s failure to obtain a timely urology referral for a resident with a neurogenic bladder and chronic Foley catheter, despite ongoing catheter-related problems. The resident was admitted with an indwelling Foley catheter and had a care plan addressing catheter management, including monitoring for discomfort, UTI signs, and pain. On one occasion, the resident returned from an appointment with the Foley catheter out and reinsertion attempts by staff were unsuccessful due to resistance; the provider was notified and ordered the catheter left out with bladder scans every eight hours. The catheter was successfully reinserted the following day. Subsequently, the resident experienced a large amount of bleeding and blood clots from the penis, and the on-call provider ordered labs and a urine culture. The resident later presented with excessive bleeding and clots around the urinary catheter and was sent to the hospital, where a CT scan showed the catheter tip in the penile urethra with the balloon distended just proximal to the tip. Interviews with nursing staff revealed that the resident’s catheter had been difficult to replace and that staff had ongoing difficulty changing it, with multiple catheter dislodgements and frequent leakage reported over the course of the year. LPNs reported that the expectation was for staff nurses to attempt catheter changes and refer out if unsuccessful, and one LPN stated that the resident was recommended to follow up with urology and have catheter changes done there due to the increased difficulty. Another LPN confirmed that the expectation was to schedule residents with outside providers as soon as possible and acknowledged that this resident did not see urology until many months after the documented catheter complications and difficulties. The surveyors concluded that the facility failed to refer the resident to an outside provider in a timely manner while there was an ongoing urinary catheter issue.
Failure to Notify Provider After Dialysis Refusal
Penalty
Summary
The facility failed to ensure that the provider was consulted when a resident refused dialysis services. The resident was admitted to the facility on 12/18/25 and had a physician's order dated 12/26/25 for dialysis on Monday, Wednesday, and Friday with stretcher transport. On 2/9/26, a progress note documented that the resident left for dialysis, and a dialysis communication form documented that the resident attended dialysis but refused treatment and was returned to the facility without interventions. During interviews, an LPN stated the dialysis center called the facility to report that the resident did not receive dialysis, but no progress note was written documenting this and the Nurse Manager was notified. The UM stated she was not aware the resident did not receive dialysis, and the NP stated neither the nurse nor the dialysis center notified her that the resident did not receive dialysis and that she expected to be notified.
Delayed Resolution of Missing Dentures Grievance
Penalty
Summary
The facility failed to promptly resolve a grievance involving missing top dentures for one resident. A grievance form completed by an LPN documented that the resident’s family reported the dentures were missing, a room sweep was completed, and the concern was reported to the DON. The grievance was then received by the former SW, who contacted the family and discussed whether Medicaid would replace the dentures if the resident was no longer Medicaid-pending; the family stated the resident had already been approved in Delaware and agreed to wait for verification with the Business Office. After the scheduled discussion with the Business Office, the record did not show documented investigative findings, corrective actions, or grievance closure for several months. Later email correspondence showed the SW requested dental enrollment for the resident and the dentist sought confirmation about the resident’s representative payee, then stated the resident did not qualify for the dental program. During interview, the SW could not explain the extended timeframe, and the current BOM confirmed the facility could have obtained dental services on a fee-for-service basis and did not need to wait for Medicaid eligibility determination. Resolution of the denture replacement did not occur until January 2026, about eight months after the grievance was initiated.
PRN Lorazepam Extended Without Required Rationale or Duration
Penalty
Summary
The facility failed to ensure that an as-needed psychotropic medication ordered for one resident, R11, had a documented rationale and duration when the order was extended beyond the 14-day limit. R11 was admitted with multiple diagnoses including dementia, psychotic disturbance, mood disturbance, and anxiety. A significant change MDS documented cognitive impairment, psychotropic medication use, and physical behaviors occurring 4 to 6 days in a seven-day period. On 10/16/25, hospice ordered lorazepam 0.5 mg every 6 hours as needed for anxiety/agitation, and the order was written the same day. The order was extended on 10/23/25, but the record lacked evidence of a rationale for the extension. An MRR on 10/19/25 documented that a duration must be specified for PRN psychoactive medications and noted there was no exception for hospice patients; the MRR lacked evidence of review by an attending provider, and E27, an LPN, signed the comments section. The same pattern continued with later lorazepam orders. The PRN lorazepam order was written again on 10/23/25 and discontinued on 11/6/25, then reordered on 11/12/25 and discontinued on 12/30/25. On 12/29/25, lorazepam 0.5 mg every 6 hours as needed for anxiety was ordered again and extended on 1/2/26 without documented rationale. Another MRR on 1/14/26 again stated that a duration must be specified for PRN psychoactive medications and that the first order is limited to 14 days unless the prescriber documents a rationale to continue it; this MRR also lacked evidence of review by an attending provider, and E4, the ADON, signed the comments section. On 1/22/26, the lorazepam order was written as indefinite with no duration, and although a psychiatric follow-up note documented a rationale for extending the medication, it did not include an end date. During interviews, staff confirmed the lack of documented rationale or duration, and the NHA, ADON, and NP acknowledged the findings, with the NP stating the medication was reordered without duration and rationale because the resident was on hospice.
Inaccurate MDS Coding for Foot Infection
Penalty
Summary
The facility failed to ensure the MDS was accurate for three residents, R6, R17, and R143, by documenting an infection of the foot on their assessments. R6 was admitted on 12/16/25, and a 12/20/25 MDS assessment documented an infection of the foot; during an interview on 2/18/26, the MDS Coordinators confirmed the coding was based on a fungal infection documented by the podiatrist. R17 was admitted on 1/8/26, and a 1/15/26 MDS assessment documented an infection of the foot; during the same interview, the MDS Coordinators confirmed the coding was based on a fungal infection documented by the podiatrist. R143 was admitted on 9/21/25, and a 11/11/25 quarterly MDS assessment documented an infection of the foot; during the interview, the MDS Coordinators again confirmed the coding was based on a fungal infection documented by the podiatrist. The findings were reviewed during the exit conference with the NHA, ROD, and DON.
Failure to Provide ADL Nail Care
Penalty
Summary
The facility failed to provide ADL care for a dependent resident. R131 was admitted with a diagnosis of stroke infarction affecting the right side, and the quarterly MDS documented that the resident was dependent on staff for bathing and dressing. The care plan also identified the resident as dependent for ADL care, but it did not include a refusal of nail care. During observations on 2/9/26 and 2/10/26, R131’s left and right fingernails were long, and black debris was observed under the fingernails of the right hand. During interview, a CNA stated that when she gives a bath, she washes the resident and does hair and nails, and that R131’s bath days were Mondays and Thursdays. The UM confirmed that the 3:00 PM to 11:00 PM shift documented that R131 received his bath, yet the resident’s fingernails remained long with black debris underneath.
Respiratory Equipment Not Stored Properly
Penalty
Summary
Safe and appropriate respiratory care was not provided for one resident with chronic obstructive pulmonary disease and chronic respiratory failure. The resident was admitted on 1/31/26, and an initial MDS on 2/7/26 documented moderately impaired cognition with a BIMS of 11. A physician’s order dated 2/10/26 directed that the nebulizer face mask be placed in a plastic bag after each use, but a review of the treatment administration record on 2/15/26 lacked evidence of an order directing that the mask and tubing be stored in a protective plastic bag when not in use. During observations on 2/9/26 and 2/10/26, the resident’s oxygen tubing was found on the floor and not in a protective plastic bag, and the nebulizer face mask was on the bedside table and not in a protective plastic bag. During an interview on 2/10/26, an LPN confirmed that oxygen tubing and a nebulizer face mask are required to be stored in a protective plastic bag when not in use, and immediately placed the oxygen tubing and mini neb into a protective plastic bag.
Failure to Provide Ordered Pain Medication
Penalty
Summary
Safe, appropriate pain management was not provided for one resident reviewed for pain. R141 was admitted with diagnoses including spondylopathy of the cervical region and muscle weakness, and a quarterly MDS documented that the resident was alert, oriented, and had pain. The baseline care plan identified potential for pain and actual chronic pain-related conditions, including spinal stenosis of the cervical region, mobility impairment, spondylopathy, and chronic pain syndrome. The record also noted that R141 had a surgical cervical fusion. The clinical record showed that an order for oxycodone 5 mg, 2 tablets by mouth as needed for pain for 14 days was discontinued, and a later order for oxycodone 2 tablets of 5 mg by mouth as needed for chronic pain was reissued. The MAR showed the oxycodone was not given at 4:40 AM. A progress note at 7:10 AM documented that the DON was called to R141's room because the resident was complaining of neck pain rated 7/10, and the nurse practitioner was notified and gave a new order for oxycodone 2 tablets of 5 mg by mouth. During interview, R141 stated having significant pain throughout the night and said the resident requested the prescribed oxycodone but was told by the RN that it was not available. A late entry note by the RN stated the medication was not given and that the RN called the provider for an order so the medication could be pulled from the Pyxis but was unsuccessful. The RN later confirmed the prescription had expired and that a new order was not obtained to use back-up pain medication at the facility.
Failure to Complete Dialysis Catheter and Pre/Post Dialysis Assessments
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for one resident who required hemodialysis. The resident was admitted to the facility with renal failure and had a care plan that included dialysis-related interventions such as attending scheduled dialysis appointments and monitoring for signs and symptoms of infection at the access site, renal insufficiency, bleeding, hemorrhage, bacteremia, and septic shock. The resident’s admission MDS documented hemodialysis and dependence for ADLs, and a physician’s order specified dialysis on Monday, Wednesday, and Friday with stretcher transport. The record lacked evidence of an order to assess the resident’s dialysis catheter. In addition, review of the resident’s progress notes and assessments showed no evidence that pre-dialysis and post-dialysis assessments were completed or documented. During interview, an LPN stated the expectation was for nursing staff to complete and document pre- and post-dialysis assessments, including assessment of the dialysis catheter, and the UM confirmed the expectation to assess the resident before and after dialysis and noted the progress notes lacked evidence of those assessments.
Failure to Ensure Provider Review of Medication Regimen Review Irregularities
Penalty
Summary
The facility failed to ensure that a licensed pharmacist’s monthly drug regimen review included review of irregularities by the attending provider or designee, as required by the facility’s Pharmacy Services – Drug Regimen Review policy. The policy stated that the pharmacist would report irregularities to the attending physician, medical director, and DON, and that the attending physician must document in the resident’s medical record that the irregularity was reviewed and what action, if any, was taken. Record review showed that for three residents, irregularities identified in medication regimen reviews were not reviewed by an attending provider or designee. For one resident admitted with hypothyroidism, a medication regimen review noted charting omissions for levothyroxine, but there was no attending or designee signature on the review document. For another resident, multiple medication regimen reviews identified irregularities on several dates, yet the comments sections lacked evidence of provider review and were signed by nursing staff or the ADON instead. For a third resident, several medication regimen reviews also identified irregularities, but the reviews lacked evidence of attending review and were signed by the ADON or an LPN. During interviews, the NP and ADON confirmed that providers did not review all medication regimen reviews with documented irregularities.
Unnecessary Medication Use and Delayed Discontinuation of Metoprolol
Penalty
Summary
The facility failed to ensure that one resident’s drug regimen was free from unnecessary medication. For R11, a physician ordered Metoprolol on 9/23/25 to be given once daily for hypertension, with instructions to hold the dose if systolic blood pressure was greater than 130 or heart rate was less than 60. Review of the MAR showed the medication was held frequently over several months: 19 of 31 doses in October 2025, 25 of 30 doses in November 2025, 11 of 31 doses in December 2025, and 9 of 31 doses in January 2026 because of low systolic blood pressure or heart rate. The Metoprolol was discontinued on 2/9/26. During interview, the NP confirmed the medication had been discontinued in February because low blood pressure made it no longer appropriate and stated she had not been informed of the frequency of the held doses; she said that if she had been notified, she would have discontinued it earlier.
Metoprolol Given Despite Hold Parameters
Penalty
Summary
The facility failed to ensure that one resident’s metoprolol was held when ordered blood pressure or heart rate parameters were not met. A physician order dated 9/22/25 directed that metoprolol be given daily for blood pressure and held if systolic blood pressure was less than 130 or heart rate was less than 60. Review of the resident’s record showed multiple instances in October 2025, November 2025, December 2025, January 2026, and February 2026 when metoprolol was administered despite vital signs being below the ordered hold parameters, including low systolic blood pressures and low heart rates on several occasions. An MRR irregularity report dated 12/7/25 documented that metoprolol was not always held as required by the physician’s order, but the report lacked evidence of review by the attending physician and was signed by an LPN. A later MRR irregularity report dated 2/7/26 again documented that metoprolol was not always held and noted consideration of discontinuation; the medication was discontinued on 2/9/26 and the report was signed by the NP on 2/11/26. During interview, the LPN who administered the medication in January and February confirmed that the resident received metoprolol when vital signs did not meet ordered parameters and stated, "If the one vital sign is good [within parameters] then I give the medication based on that." The NP confirmed that the medication was to be held for either parameter and was unaware it had been administered outside of parameters.
Delayed Replacement of Lost Dentures
Penalty
Summary
The facility failed to promptly initiate replacement of a resident’s lost top dentures within three days after notification of the loss. A grievance form documented that the resident’s top dentures were missing, and an LPN completed a room sweep with a second sweep planned for the overnight shift. The concern was reported to the DON, and the grievance noted a meeting with the Business Office to explore Medicaid eligibility for denture replacement. During later interviews, the SW was unable to explain the extended delay, and the current Business Office Manager confirmed the facility could have obtained dental services on a fee-for-service basis and did not need to wait for a Medicaid eligibility determination before replacing the dentures. The facility did not document extenuating circumstances to justify the delay.
Failure to Assist Residents With Routine Dental Services
Penalty
Summary
The facility failed to provide or obtain routine dental services for two sampled residents, including one resident who was cognitively intact and had obvious or likely cavity or broken natural teeth. The facility policy stated it would accommodate needed dental services and assist residents in making appointments if necessary or requested. R2 was admitted with broken/carious teeth, had a care plan that included coordinating dental care and transportation, and later stated he had had broken teeth since admission and wanted them pulled, but he had not seen a dentist since arriving at the facility. Observation showed missing teeth, broken teeth on the bottom right, and miscolored teeth and gums, and an oral cavity assessment later documented some natural teeth lost and broken, loose, or carious teeth. Facility staff stated that residents with broken teeth, abscesses, or dental pain would be assessed and then referred to the social worker to determine whether they were part of the facility’s dental program or needed outside scheduling, and the social worker confirmed R2 was not enrolled and had no dental appointment. R56 was admitted with dental health problems related to poor oral hygiene and broken carious teeth, and the care plan directed staff to coordinate dental care and monitor oral problems. The record showed a new patient dental exam occurred, but the report identified the deficiency as involving two residents out of two sampled residents for dental services because the facility failed to assist them in obtaining routine dental services.
Improper Dating of Opened Thickened Water in Nutrition Refrigerators
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served in a manner that prevents food borne illness to residents. During observation, the Sussex Hall nutrition refrigerator contained three opened cartons of thickened water that were incorrectly dated to reflect the date of disposal according to the manufacturer’s recommendations; one carton was dated February 3, 2026, and two cartons were dated January 31, 2026. The manufacturer’s instructions on the cartons stated that once opened, any remaining product should be discarded after four days. During a separate observation at 10:08 AM, the Henelopen Hall nutrition refrigerator contained one carton of thickened water that was also incorrectly dated.
Medical Director Failed to Ensure Drug Regimen Review Documentation Compliance
Penalty
Summary
The facility failed to ensure the Medical Director fulfilled responsibility for implementing the Drug Regimen Review policy in a manner consistent with current professional standards of care regarding provider documentation of identified irregularities. The facility job description for the Medical Director stated responsibilities included providing guidance and education to physicians, nurse practitioners, and physician assistants regarding best practices in LTC and ensuring compliance with federal, state, and local healthcare regulations, including CMS and CDC guidelines. The facility policy on Drug Regimen Review stated that the attending physician must document in the resident’s medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. During interview, the ROD confirmed that the Medical Director was not ensuring provider compliance with the drug regimen review policy and stated that the DON was reviewing the irregularities and notifying the provider instead.
Inaccurate Fall Incident Documentation
Penalty
Summary
The facility failed to ensure accuracy of resident records for one resident reviewed for falls when the resident’s fall incident report contained inaccurate information about an injury. A progress note documented that while a staff member was at the medication cart passing afternoon medications, a loud sound was heard from the dining area and the resident was found lying face down on the floor with a hematoma noted on the forehead. However, the incident report for the same fall documented that no injuries were observed at the time of the incident in the injuries observed section. During interview, a staff member confirmed the finding and stated that the injury had been written in another section of the report.
Non-Emergent Overhead Paging Disrupts Homelike Environment
Penalty
Summary
The facility failed to honor residents’ right to a safe, clean, comfortable, and homelike environment by repeatedly using an overhead paging system for non-emergent staff communication. During random observations on multiple dates and times, surveyors heard overhead paging announcements used to communicate between staff members during the day. During a resident council meeting, an anonymous resident reported that the overhead paging by facility staff was unpleasant. In a subsequent interview, the Nursing Home Administrator (E1) confirmed that the facility routinely used overhead paging to communicate with staff during the day, stopping only after 7:00 PM. These observations and interviews were reviewed with the NHA (E1), Regional Operations Director (E2), and DON (E3) during the exit conference. No specific resident medical histories or clinical conditions were described in relation to this deficiency, and the report focuses on the environmental impact of overhead paging on residents’ comfort and homelike surroundings.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident (R2) from abuse by another resident (R1), resulting in physical and psychosocial harm. R1 and R2, both with severe cognitive impairment, were roommates and had escalating verbal altercations over a period of several weeks. Documentation showed that R1 exhibited increasing agitation, aggression, and behavioral disturbances, including verbal and physical aggression toward staff and other residents. Despite repeated documentation of these behaviors and ongoing conflict between the two residents, the facility did not revise R1's care plan, reassess the risk of the roommate pairing, or implement additional interventions to prevent harm. Staff interviews and progress notes indicated that R1's behaviors became more difficult to redirect, and that both residents were involved in frequent verbal altercations. Staff reported that the behaviors had been ongoing and that interventions such as redirection were unsuccessful. The social worker was not notified of the escalating conflict, and no changes were made to the residents' room assignments or supervision levels prior to the incident. The facility also failed to obtain behavioral health services for R1, despite documentation of severe behavioral symptoms and cognitive impairment. The situation culminated in an unwitnessed physical altercation in which R2 was found on the floor with a head injury, and R1 was observed standing over him. R2 required transport to the hospital for evaluation and was diagnosed with a head injury, neck muscle strain, and a suspected wrist ligament injury. Interviews with staff and R2 confirmed that R1 had threatened and physically harmed R2, resulting in fear and ongoing psychosocial distress for R2. The facility's lack of timely intervention and failure to address the escalating conflict directly led to the incident of abuse.
Failure to Timely Report Suspected Abuse Allegations
Penalty
Summary
The facility failed to report incidents of suspected abuse involving two residents within the required two-hour timeframe to the State Agency. In the first case, a resident experienced a psychotic episode and made physical contact with three other residents. The incident occurred at approximately 9:00 PM, but the report was not submitted to the State Agency until the following afternoon, well beyond the mandated reporting window. Staff interviews confirmed the timing of the incident and the delayed reporting, with the Assistant Director of Nursing acknowledging the late submission was due to the facility's desire to provide accurate data. In the second case, a resident alleged that her husband, who was also a resident, choked her. This allegation was reported by a CNA to a nurse, who then reported it to the nursing supervisor as per facility protocol. However, the Assistant Director of Nursing was not made aware of the allegation, and there was uncertainty among staff regarding the exact date of the incident and whether it was properly reported. The social worker confirmed that the resident's history of making similar allegations was discussed in an interdisciplinary team meeting, but there was no clear documentation or timely reporting of the specific abuse allegation to the State Agency.
Failure to Maintain Accurate Clinical Documentation
Penalty
Summary
The facility failed to ensure that the clinical record for one resident contained accurate and complete documentation. Specifically, after an incident, there was no evidence in the resident's clinical record of a progress note, consult, medication review, or visit summary. Although the facility provided electronic communication from a nurse practitioner indicating the resident was seen for a wellness check, an LPN confirmed that the resident had not been seen by a psychiatrist on the date in question and that no corresponding progress notes were present in the electronic medical record. This lack of accurate documentation was confirmed during interviews with facility staff and reviewed during the exit conference.
Failure to Maintain Dignified Dining Experience Due to Soiled Bed Linens
Penalty
Summary
A resident with diagnoses including generalized osteoarthritis and chronic obstructive pulmonary disease, and who was cognitively intact, was observed seated in a wheelchair at the foot of his bed. The resident's bed linens were visibly soiled with a large brown stain and the room was described as very odorous. The resident's breakfast tray was present, and the resident expressed distress about being expected to eat while his bed remained soiled, stating that staff had promised to change the linens but had not returned. A registered nurse acknowledged the need to change the bed linens and a second request was made before the bed was eventually changed, resulting in a delay of at least 14 minutes. The nurse explained the delay was due to staff passing meal trays and not wanting them to sit out. The Director of Nursing and Assistant Director of Nursing later confirmed that the bed linens should have been changed before the resident was provided breakfast. This sequence of events resulted in the resident not receiving care in a manner that maintained a dignified dining experience.
Verbal Abuse of Resident by Staff Member
Penalty
Summary
A deficiency occurred when a staff member, specifically a medical records clerk, engaged in a verbal altercation with a resident. The incident was witnessed by a social worker, who observed the staff member using an argumentative tone and, after being advised to disengage, turning back to confront the resident and using profanity. The resident involved was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The facility's policy prohibits verbal abuse, including the use of disparaging or derogatory language toward residents. Interviews with facility staff provided varying accounts of the incident. The Social Service Director reported hearing raised voices and stated that the resident used profanity toward staff, but could not recall if the staff member used profanity toward the resident. The Assistant Director of Nurses remembered the incident but did not provide further details. The administrator confirmed that the staff member was immediately removed from the situation. The incident was reported and reviewed as part of the facility's procedures for preventing and identifying abuse.
Misappropriation of Resident Medication by LPN
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) took a resident's prescribed Percocet pain medication from the medication cart without authorization. The incident began when two blister packs of Percocet were delivered by the pharmacy and were initially placed incorrectly on the medication carts, leading to a discrepancy in the count. After the error was corrected, the narcotics were counted and recorded as correct at the start of the LPN's shift. However, following the LPN's shift, it was discovered that one blister pack containing 30 tablets was missing, and only two tablets remained in the other pack. The facility's investigation determined that the LPN was responsible for the missing medication, and the nurse did not respond to attempts to contact her after leaving the building. The resident involved had a physician's order for Percocet two tablets every six hours for pain management. The facility's policy defined misappropriation as the wrongful use of a patient's belongings or medication without consent. The incident was identified through medication count discrepancies and confirmed by pharmacy records. The LPN's actions resulted in the misappropriation of the resident's medication, as confirmed by interviews and documentation reviewed during the investigation.
Failure to Report Alleged Abuse as Required by Policy
Penalty
Summary
The facility failed to follow its own policies and procedures for reporting suspected abuse to the State Survey Agency (SSA) for one resident. According to the facility's policy, all alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately, but not later than two hours after the allegation is made if it involves abuse or results in serious bodily injury, or within 24 hours if it does not. In this case, a resident with moderate cognitive impairment reported to the Assistant Director of Nurses (ADON) that she was afraid of a female staff member. The ADON did not report this allegation to the Abuse Coordinator or the SSA, citing the resident's confusion as the reason for not reporting. The Director of Nurses (DON) also confirmed that the allegation was not reported or investigated, and the Administrator acknowledged that the report should have been made regardless of the resident's cognitive status. The investigation revealed that the resident's statement about being afraid was not documented or reported in a timely manner, and the initial documentation by the ADON was unsigned and undated. The ADON later provided a revised statement indicating the resident was confused and did not recall the earlier conversation. Despite this, the facility's policy requires all allegations to be reported and investigated, regardless of the resident's mental status. The failure to report and investigate the allegation as required by policy had the potential to contribute to continued abuse for this resident and others.
Failure to Investigate Resident's Allegation of Staff Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of staff-to-resident abuse involving one resident out of a sample of 46. According to the facility's policy, all alleged violations must be thoroughly investigated, and the results reported to the administrator and appropriate officials. On the date in question, a resident with moderate cognitive impairment (BIMS score of 11/15) reported to the ADON that she was afraid of a female staff member with a hairband and long, black hair. Despite this report, no investigation was initiated at that time. Interviews revealed that the DON considered the resident to be confused and did not report or investigate the allegation, stating that it would be addressed during the ongoing five-day investigation for another resident. The ADON also confirmed that no investigation was conducted due to the resident's confusion. The administrator later acknowledged that the allegation had not been reported to her and confirmed that any report of fear from a resident, regardless of cognitive status, should have been reported and investigated. This lack of action resulted in the facility not meeting its policy requirements for responding to and investigating allegations of abuse.
Missed Wound Care Treatment and Care Plan Update
Penalty
Summary
A deficiency occurred when a resident with a history of bilateral above-knee amputations, peripheral vascular disease, and type 2 diabetes mellitus with neuropathy did not receive wound care treatment as ordered by the physician. The resident, who was cognitively intact, reported that the dressing on his left stump had not been changed as scheduled. Observation confirmed that the bandage was dated two days prior, and review of the Treatment Administration Record showed the wound care was not performed on the required date. The physician's order specified that the wound should be cleaned with normal saline and Silvasorb Alginate applied every other day, but this was not followed. Further review revealed that the resident's care plan was not updated to reflect the new wound care treatment ordered by the wound care physician. Interviews with nursing staff and review of the electronic medical record confirmed the omission of the scheduled treatment and the lack of care plan revision. The Director of Nursing and Assistant Director of Nursing acknowledged that the treatment was missed and the care plan did not include the current intervention.
Failure to Provide Ordered Low Air Loss Mattress for Pressure Ulcer Care
Penalty
Summary
A resident with dementia and type 2 diabetes was admitted to the facility and later developed a stage 2 pressure sore on the left buttock and a deep tissue injury on the right heel. The resident was assessed as being at risk for further skin breakdown, and the care plan included the use of a pressure reducing mattress. Physician orders were in place for wound care, including cleansing and dressing changes, but did not specify the use of a low air loss mattress. During wound rounds, the wound care physician ordered a low air loss mattress to prevent worsening of the resident's wounds, and the unit manager reported placing the order in the facility's maintenance request system on the same day. Despite these orders, multiple observations over several days showed that the low air loss mattress was not applied to the resident's bed, and the resident continued to lie on a regular pressure reducing mattress. The unit manager and assistant director of nursing confirmed that the low air loss mattress had not been provided as expected, and that it should have been placed on the resident's bed the same day the order was made. This failure to implement all planned interventions for pressure ulcer care created the potential for further unnecessary skin breakdown for the resident.
Failure to Follow Care Plans During Incontinence Care Results in Resident Injuries
Penalty
Summary
The facility failed to prevent injuries during incontinence care for two residents by not following established care plans and protocols. One resident, who had a diagnosis of cerebral infarction and was dependent on staff for all activities of daily living due to contractures and impaired extremities, required two-person assistance for bed mobility and incontinence care. During an episode of incontinence care, only one CNA was present, and the second CNA left the room to retrieve a sheet. While unattended, the resident rolled off the bed and sustained a laceration to the forehead, requiring emergency department evaluation. Another resident, with diagnoses including schizophrenia, morbid obesity, and congestive heart failure, was non-ambulatory and required two-person assistance with a Hoyer lift for all transfers according to the care plan. Despite this, two CNAs attempted to assist the resident to stand next to the bed for ADL/peri-care without using the mechanical lift. The resident became weak, was lowered to the floor, and sustained a skin tear to the abdomen. Four staff members and a Hoyer lift were then required to return the resident to bed. In both cases, staff did not adhere to the residents' care plans, which specified the need for two-person assistance and the use of a mechanical lift for transfers. These failures resulted in preventable injuries during routine care activities. Interviews with staff and review of documentation confirmed that the required protocols were not followed at the time of the incidents.
Lack of Physician Orders and Documentation for Catheter Care
Penalty
Summary
The facility failed to ensure that two residents with indwelling urinary catheters had appropriate physician orders and documentation for the use and routine care of their catheters. For one resident with quadriplegia and urinary retention, there were no orders in the electronic medical record (EMR) for the use or care of the urinary catheter, and no evidence in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) that routine catheter care was provided. The resident's care plan indicated a suprapubic catheter was in place and scheduled to be changed every four weeks at a urology office, but this was not reflected in the physician orders or care documentation. Interviews with the Director of Nursing (DON) and Assistant DON (ADON) confirmed that their expectation was for physician orders to be present for catheter use and care. Another resident, admitted with acute kidney failure and neuromuscular dysfunction of the bladder, also lacked orders for catheter care in the EMR, MAR, and TAR, despite having an order for a urinary catheter. The resident reported that the catheter was overdue for a change by at least a month, and the ADON confirmed that the last change occurred during a hospital visit for a urinary tract infection. The ADON also noted that the facility's policy was to change catheters only when symptomatic, and that previous orders did not transfer over from the hospital. These omissions resulted in a lack of documented routine catheter care for both residents.
Failure to Assess and Authorize Bed Rail Use for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident with quadriplegia was appropriately assessed and authorized for the use of side rails on his bed. The facility's policy required that alternatives be attempted before installing side rails, that a physician's order be obtained, and that the use of side rails be included in the resident's care plan. However, review of the resident's records showed no physician's order for side rails, no documentation in the care plan regarding their use, and no evidence that alternatives were considered. The Device/Restraint Assessment and Consent Form noted the presence of 1/4 side rails but did not provide a rationale, document attempted alternatives, or indicate that risks had been discussed with the resident. Observations confirmed that the resident, who was completely dependent on staff for all mobility and unable to use the side rails due to quadriplegia, consistently had side rails raised on both sides of his bed. Interviews with the resident and facility staff, including the ADON and DON, confirmed that the resident could not use the side rails and that their presence was not appropriate. The lack of assessment, documentation, and proper authorization for the use of side rails constituted the deficiency.
Medication Error: Administration Without Physician Order
Penalty
Summary
A registered nurse (RN) administered Ativan, an anxiolytic, and morphine, a narcotic pain medication, to a resident without a physician's order for these medications. The RN did not verify the resident's identity by checking the armband or asking the resident's name before administering the medications. The error was discovered immediately after administration when the RN realized the medications were given to the wrong resident. The resident who received the medications had a medical history including heart failure, anemia, and chronic obstructive pulmonary disease (COPD), and did not have orders for Ativan or morphine on their Medication Administration Record. The facility's policy required staff to prepare medications for one resident at a time, confirm the correct medication and dose, and verify the resident's identity, all of which were not followed in this incident.
Failure to Implement Effective Infection Control and PPE Use
Penalty
Summary
The facility failed to implement its infection prevention and control program by not ensuring proper use of personal protective equipment (PPE) for a resident on contact isolation and by not timely identifying and isolating a resident with COVID-19 symptoms. For one resident with a PEG tube and a diagnosis of dysphagia following cerebral infarction, the care plan and physician orders required Enhanced Barrier Precautions, including the use of gown and gloves during high-contact care such as medication administration via the feeding tube. However, during observation, an LPN administered medications through the PEG tube wearing only gloves and a mask, omitting the required gown. The LPN stated she believed a gown was not necessary for this task, despite signage and orders indicating otherwise. The Director of Nursing later confirmed that the expectation was for nurses to wear a gown, mask, gloves, and eye protection during such procedures. In a separate incident, another resident with a history of rheumatoid arthritis and chronic pain syndrome reported feeling unwell and experiencing multiple episodes of vomiting, requiring several bed changes. Despite these symptoms, there was no documentation of vomiting in the resident's record for the day in question, and no isolation signage or appropriate trash receptacles were present in the room. The DON and ADON were unaware of the resident's condition until the following day, and a CNA confirmed that the resident had been sick multiple times without any isolation measures being implemented. The resident was later placed on contact isolation after testing positive for COVID-19, but this was not done in a timely manner. These findings indicate that the facility did not follow its own infection control policies regarding the use of PPE and timely identification and isolation of residents with infectious symptoms. The lack of adherence to established protocols and communication breakdowns among staff contributed to the deficiencies observed during the survey.
Failure to Complete PASARR Screenings for Residents with New or Worsening Psychiatric Conditions
Penalty
Summary
The facility failed to ensure that referrals for PASARR screenings were completed for five residents who had changes in their mental health conditions or new psychiatric diagnoses. For instance, one resident was admitted with a diagnosis of persistent mood affective disorder and later diagnosed with psychosis, but the facility did not submit a PASARR level II review. Another resident was admitted with anxiety disorder, adjustment disorder with depressed mood, and insomnia, but the facility did not verify the accuracy of the PASARR I completed by the hospital and failed to submit a resident review PASARR for the new diagnoses. Similarly, other residents with new or worsening psychiatric conditions did not have the required PASARR screenings submitted by the facility, despite significant changes in their mental health status and medication adjustments. These failures were confirmed through interviews with facility staff and email correspondence with the State PASARR Authority, which indicated that the facility should have submitted resident review PASARRs for these cases. The lack of appropriate PASARR screenings for residents with new or worsening psychiatric conditions represents a significant deficiency in the facility's compliance with regulatory requirements. The findings were reviewed with the facility's nursing home administrator, director of nursing, assistant director of nursing, and corporate representatives during the exit conference.
Failure to Provide Food in Appropriate Form for Resident
Penalty
Summary
The facility failed to prepare food in a form designed to meet the individual needs of a resident (R14). R14 was admitted to the facility on 6/19/18 and had a physician's order dated 2/28/24 for a regular diet with ground meats/mechanical soft texture and regular/thin consistency liquids. A swallow study completed on 3/8/24 confirmed that R14 required ground solids and regular liquids. However, on 3/11/24, during lunch, R14 was served whole cauliflower florets instead of the prescribed ground cauliflower. R14, who does not use dentures and has no natural teeth, attempted to eat the cauliflower but found it too hard and spit it out, stating it was too difficult to consume. The meal ticket also indicated that R14 should have received ground cauliflower, not whole florets. Interviews with staff confirmed the deficiency. E16 (RN) acknowledged that R14 had whole cauliflower florets despite the meal ticket specifying ground cauliflower. E22 (Food Service Director) confirmed that the cauliflower was not ground and mentioned that it was challenging to determine the appropriate consistency. E23 (Dietician) also confirmed that R14 was on a ground diet and had failed his swallow study, and that the cauliflower served on 3/11/24 was not ground. These findings were reviewed with the Nursing Home Administrator (E1), Director of Nursing (E2), Assistant Director of Nursing (E3), and a corporate representative (E4) during the exit conference on 3/20/24.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment for a resident in room [ROOM NUMBER]. Observations revealed a substantial amount of dirt and food crumbs scattered throughout the bedroom, and the bathroom had small, circular black debris and a brown circular area next to the toilet. Additionally, approximately 3 feet of baseboard was peeling off the wall and onto the floor. The resident reported that the baseboard had been in this condition for a year and that maintenance had been informed. Despite these issues being observed on 3/11/24, the room remained unclean the following day, and the resident confirmed that no cleaning had been done on 3/11/24. Interviews with staff confirmed the unclean conditions and the long-standing issue with the baseboard. E24, a floor tech, acknowledged the unclean state of the room and proceeded to clean it, removing the black debris and the brown area by the toilet. E24 also confirmed that the baseboard issue had been reported to E26, the Director of Maintenance, about a year ago. E26 admitted that the issue might have been verbally communicated but was not entered into the maintenance system for follow-up. The baseboard was eventually fixed by 3/18/24. E25, the Director of Environmental Services, confirmed that resident rooms are supposed to be cleaned daily, including sweeping, wet mopping, and bathroom cleaning. The resident expressed a preference for E24 to clean the room but was also acceptable to having two of the four housekeepers clean the room.
Failure to Review Total Program of Care for Resident with Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure that the physician reviewed the total program of care, including medications and treatments, for a resident (R309) who was admitted with an indwelling urinary catheter. Upon admission, an assessment indicated the presence of the catheter, but the physician's progress note on the same day lacked any mention of it. The resident confirmed the use of the catheter due to neurogenic bladder. It was later confirmed by a nurse practitioner that the physician did not mention or assess the catheter, resulting in six days without proper physician orders for the catheter. These findings were reviewed with the nursing home administrator, director of nursing, assistant director of nursing, and a corporate representative during the exit conference.
Lack of Qualified Food Service Personnel
Penalty
Summary
The facility failed to ensure that a qualified person in charge was present in the kitchen during all hours of food service operation. During an interview, a dietary aide disclosed that only one staff member in the food service department possessed a valid Food Protection Manager certificate from an Accredited Food Safety Program. These findings were reviewed with the nursing home administrator, director of nursing, assistant director of nursing, and a corporate representative during the exit conference.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served in a manner that prevents foodborne illness to the residents. During an initial tour of the kitchen, a partially uncovered container of stuffed peppers was found in the walk-in refrigerator, exposing the food to potential contaminants. Additionally, the reach-in refrigerator contained an unlabeled and undated plate of liverwurst. In the nourishment refrigerators located in the Henlopen and Sussex hallways, cartons of Nutritional Shake were found undated or past the discard date as per the instructions on the carton. Furthermore, a dietary aide tested the sanitizer level of the solution in two red sanitizing buckets, and the test strips indicated that the chemical concentration was insufficient for proper sanitization. These findings were confirmed with the Nursing Home Administrator (NHA) and reviewed with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and a corporate representative during the exit conference.
Non-Functional Call Bell System in Resident Room
Penalty
Summary
The facility failed to ensure that the call bell system in room [ROOM NUMBER] was functioning properly. During a random observation, it was found that the call bell box on the wall was taken apart with exposed wires, rendering both A and B bed call bells non-functional. There was no alternate equipment available for the residents to call for help. An RN confirmed the issue and was unsure how long the call bells had been non-functional, estimating it might have been since the previous week. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were made aware of the issue and initially provided cow bells as a temporary solution. Further investigation revealed that a work order for the broken call bells had been submitted electronically four days prior to the observation, marked as critical. However, the Maintenance Director stated that he could not address the issue sooner. The call bell system was eventually repaired and tested, confirming it was functioning properly. The findings were reviewed with the NHA, DON, Assistant Director of Nursing (ADON), and a corporate representative during the exit conference.
Failure to Report Bruise of Unknown Origin
Penalty
Summary
The facility failed to report a bruise of unknown origin for a resident with severe cognitive impairment. The resident was noted with a left upper arm bruise during care, but no measurements or descriptions were documented in the clinical record. The resident was unable to explain the cause of the bruise. The facility did not report the incident to the state agency within the required eight-hour timeframe, nor did they notify the resident's family. This was confirmed during an interview with the Director of Nursing and other staff members.
Failure to Obtain Immediate Physician Orders for Resident Care
Penalty
Summary
The facility failed to ensure that a resident (R309) had physician orders for immediate care upon admission. R309 was admitted with an indwelling urinary catheter, but the admitting nurse did not obtain the necessary physician orders for the catheter until several days later. The resident's clinical record showed that an admission assessment was completed on the day of admission, and a care plan for the indwelling urinary catheter was initiated. However, the physician's order for the catheter was not documented until six days after admission. Interviews with staff confirmed that the admitting nurse forgot to obtain the batch orders related to the catheter from the provider. Additionally, the facility failed to ensure immediate physician orders for diabetes management for R309. Although a care plan for diabetes management was initiated on the day of admission, the admission assessment did not indicate that R309 was diabetic. A physician's order for diabetic medications was written on the day of admission, but the order for blood glucose monitoring and sliding scale insulin coverage was not documented until six days later. Interviews with staff confirmed that the admitting nurse forgot to obtain the batch orders related to diabetic management from the provider. The findings were reviewed with the nursing home administrator, director of nursing, assistant director of nursing, and corporate representative during the exit conference.
Failure to Implement Bowel Protocol for Resident with Chronic Constipation
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and physician orders for bowel and bladder incontinence care. The resident was admitted with a diagnosis of chronic idiopathic constipation and had specific physician orders for various medications to manage constipation. However, from 7/1/23 through 9/30/23, the facility did not implement the physician's orders when the resident failed to have bowel movements for nine shifts on multiple occasions. Specifically, the facility did not administer the prescribed medications such as Milk of Magnesia, Bisacodyl suppository, Bisacodyl oral tablets, Senna s tablets, and Miralax powder as required by the bowel protocol. The CNA documentation and MARs for the resident revealed a lack of evidence of monitoring and initiating the bowel protocol during the specified dates. Additionally, the progress notes lacked evidence of bowel assessments related to the dates when the resident did not have bowel movements. An interview with an RN confirmed that the bowel protocol was not followed, and the necessary medications were not administered. These findings were reviewed with the Nursing Home Administrator, Director of Nursing, Assistant Director of Nursing, and Corporate representative during the exit conference.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 50 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lewes
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Moorings At Lewes | 1.5 mi | ★★★★★ | 0 | 0 |
| Cadia Rehabilitation Renaissance | 10.2 mi | ★★★★★ | 11 | 0 |
| Delaware Bay Rehabilitation And Healthcare Center | 14.1 mi | ★★★★★ | 2 | 0 |
| Ocean Grove Post Acute | 14.9 mi | ★★★★★ | 1 | 0 |
| Polaris Healthcare And Rehabilitation Center | 17.5 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.