Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lofland Park Center during CMS and state inspections, most recent first.
Respiratory care was not provided as ordered for four residents. One resident’s BiPAP mask and tubing were not stored in the designated bag, another resident’s nebulizer equipment was left out without a plastic bag, and two residents’ oxygen concentrator filters were observed with dust despite orders for weekly cleaning. The DON and RN confirmed the improper storage and dirty filters.
Food was not stored, prepared, and served in a manner that prevents food borne illness. Surveyors observed an open bag of cheese cubes and a container of thickened juice with no open or discard dates. The cook confirmed the items were not dated or labeled and discarded them during the interview.
Improper Hoyer lift use during a transfer led to a resident falling onto the floor when two CNAs attempted to move the resident from a chair to a bed. The lift tipped over after the base was partially closed to maneuver around another resident’s recliner, and the resident reported back and R knee pain. The resident was sent to the hospital, where x-ray showed no acute fracture or dislocation.
Failure to notify provider of resident change in condition: A resident had an unwitnessed fall after reporting he hit his head, then later showed a decline in function with PT noting he seemed off, was less steady, and could not walk or stand for long. Nursing documented the change, and the resident later had another fall with severe knee pain; the record showed provider notification for the later event, but the deficiency involved the earlier failure to consult the physician when the resident’s condition changed.
A resident admitted for bipolar mood stabilization and anxiety had orders for divalproex and buspirone, and MRRs recommended dose reductions for both medications. Provider progress notes did not document a rationale or contraindication for the GDRs, and the DON confirmed the lack of supporting documentation.
A resident who was dependent on staff for ADL care did not receive required incontinent care, turning and repositioning, or hydration for several hours into the shift. The resident had cognitive impairment and needed partial to moderate assistance with toileting, and CNA documentation showed bathing, toileting, and hygiene were not completed. The CNA later acknowledged that the required care had not been provided before the resident was prepared for discharge.
A resident’s monthly pharmacist MRRs included recommendations to reduce doses of divalproex and buspirone, but the forms were not signed by the provider and there was no documentation in the EMR showing the recommendations were reviewed. The DON confirmed the missing signatures and lack of provider acknowledgement.
A resident with diabetes mellitus who was prescribed insulin did not have a physician's order for blood sugar monitoring documented in the EMR. Nursing staff and a nurse practitioner confirmed that orders for finger stick blood sugar checks are standard when insulin is administered, but this was not done for the resident, as verified by record review and staff interviews.
A resident with severe cognitive impairment was started on multiple psychotropic medications, including buspirone, lorazepam, and haloperidol, without documented discussion of risks and benefits. RNs reported that the facility’s practice is to review psychotropic medication risks versus benefits with the resident if cognitively intact or with the resident’s representative and to complete a specific disclosure form. Review of the clinical record showed no Psychotropic Medication Administration Disclosure forms and no physician progress note entries documenting risk-versus-benefit discussions for these medications.
A resident with moderate cognitive impairment had PRN orders for haloperidol IM for agitation and lorazepam PO for generalized anxiety that were written without the required 14‑day stop dates, including one PRN lorazepam order written for 180 days. Facility leadership, including an RN and the NHA, stated that the expectation was for PRN medications to have 14‑day limits so providers could evaluate usage, yet the orders for these psychotropic medications did not comply, and the physician’s progress notes lacked documented rationale to justify extending the PRN lorazepam order despite inconsistent use.
Two residents who met minimum criteria for UTI treatment based on positive urine cultures did not receive timely antibiotic therapy. One resident with a spinal cord injury and an indwelling catheter had abnormal UA findings and a urine culture showing >100,000 cfu/ml E. coli, but antibiotics were not ordered until two days after the positive results were filed to the chart. Another resident with spastic quadriplegia cerebral palsy had a urine culture showing >100,000 cfu/ml Proteus mirabilis, with sensitivity results reported the next morning, yet antibiotics were not ordered until later that day. Lab staff confirmed that results were transmitted to the facility, and nursing staff reported that any nurse could notify the physician, but antibiotics were delayed in both cases after criteria for treatment were met.
A resident with COPD and centrilobular emphysema had a physician’s order for weekly oxygen tubing changes on a specified day, with each component labeled by date and initials. Surveyors later observed that the resident’s continuous oxygen tubing and nebulizer tubing bore dates indicating they had not been changed according to the weekly schedule. An LPN confirmed she changed the continuous oxygen tubing only after an extended interval and acknowledged the nebulizer tubing, still labeled with an older date, should have been changed. This resulted in respiratory equipment not being changed per the ordered weekly schedule.
The facility failed to comply with the Delaware Board of Nursing Scope of Practice by allowing LPNs and a SW to conduct admission assessments for four residents, which should have been performed by an RN. Interviews with the DON and RN Director UM confirmed the inconsistency with regulatory requirements, as several assessments are expected to be completed by an RN at admission.
The facility failed to maintain a safe and sanitary environment for staff, with standing water observed in the service area due to water dripping from the ceiling. The NHA confirmed the water originated from a second-floor shower room, passing through a manager's office before reaching the ground floor. These findings were reviewed with the NHA and DON.
A resident's care plan was not updated to reflect their refusal to wear hearing aids, despite staff observations and orders for hearing aid use. The RN-UM and NHA confirmed the care plan was not revised, leading to a deficiency noted during the survey.
A facility failed to re-evaluate a PRN medication order for anxiety after 14 days for a resident. The resident was prescribed clonazepam to be taken as needed for anxiety, but there was no evidence of re-evaluation by a provider after the initial 14-day period. A physician acknowledged the oversight, and the issue was discussed with the NHA and DON.
Respiratory equipment not stored properly and oxygen concentrator filters not cleaned as ordered
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for four residents reviewed for respiratory equipment and oxygen concentrator care. For one resident, a physician’s order required nightly BiPAP therapy with supplemental oxygen, but the resident’s BiPAP mask was observed lying on the bedside table with the tubing on the floor and not stored in the designated bag. An RN confirmed the tubing was not stored properly and the equipment was not placed in the designated storage bag. For another resident, nebulizer equipment was observed sitting on a black stand in the room, with the T-adapter and tubing dated but not enclosed in a plastic bag; the DON confirmed the equipment had not been placed in a bag, and the resident stated staff did not come back to put it in a bag. For two additional residents, physician orders directed that the external oxygen concentrator filter be cleaned weekly, but both concentrator filters were observed with layers of dust attached. Review of the treatment administration records showed each filter had last been cleaned several days earlier, and the DON confirmed the filters should be cleaned weekly and as needed. During the observation, the DON removed the dirty filter to clean it.
Food Items Left Undated and Unlabeled
Penalty
Summary
Food was not stored, prepared, and served in a manner that prevents food borne illness to residents. During an initial kitchen tour, surveyors observed an open bag of cheese cubes with no open date or discard date, as well as a container of thickened juice with no open date or discard date. During an interview, the cook confirmed that the items were not dated or labeled and discarded both items in the trash during the interview. The findings were reviewed with the NHA, DON, and ADON during the exit conference.
Improper Hoyer Lift Transfer Resulted in Resident Fall
Penalty
Summary
A resident was not protected from an accident hazard during a transfer with a mechanical Hoyer lift. The resident was being moved from a chair to a bed when two CNAs attempted the transfer using the lift, and the resident fell from the lift onto the floor. The lift tipped over onto the resident’s right side, and the bars of the lift struck the resident’s legs. According to the facility’s incident documentation and staff statements, one CNA was operating the lift while the other guided the resident’s legs. The room was tight, and the base of the Hoyer lift was slightly closed so the lift could navigate around another resident’s recliner chair. While the resident was raised to waist level and the lift was being turned, one wheel lifted off the floor and the lift tipped over. Staff attempted to stop the fall, but the resident landed on the floor and complained of feeling a snap in the back and right knee pain. The resident was assessed and sent to the hospital for further evaluation. Hospital x-ray results of the right knee showed no acute fracture or dislocation, with degenerative changes noted in the medial compartment. The incident was documented as a fall from the Hoyer lift caused by improper use of the lift by the two staff members involved.
Failure to Notify Provider of Resident Change in Condition
Penalty
Summary
The facility failed to consult the physician when one resident experienced a change in condition after an unwitnessed fall. The resident was found on the floor in his room after reporting that he hit his head during the fall, and nursing staff completed an assessment and started neurological checks. An SBAR communication form documented that the fall was reported to the provider, the resident denied pain, no injury was noted, and the provider advised continuing neurological assessments. The record also showed that the resident later had a documented physical decline. Nursing noted that PT stated he seemed off, was not able to walk, and was less steady on his feet. PT documented difficulty standing and tolerance of standing for only 30 seconds before requesting to sit, and nursing was notified of the change in functional status. Later that day, the resident had another fall with complaint of knee pain rated 10/10, and the on-call provider was notified with orders for a left knee x-ray, Tramadol, and a lidocaine patch.
Failure to Document Rationale for Psychotropic GDRs
Penalty
Summary
The facility failed to document the rationale for contraindicated gradual dose reductions (GDRs) of psychotropic medications for one resident, R28, out of five residents reviewed for medication management. R28 was admitted to the facility on 9/26/18 and had physician orders for divalproex sodium 500 mg at bedtime for bipolar mood stabilization and buspirone 15 mg twice daily for anxiety. A monthly medication regimen review on 10/7/25 recommended attempting a dose reduction of divalproex to 250 mg, and a later MRR on 1/8/26 recommended attempting a dose reduction of buspirone to 10 mg. Review of provider progress notes for the relevant months did not show a rationale or contraindication for either GDR, and the DON confirmed during interview that the progress notes lacked evidence of a rationale or contraindication for the GDRs.
Failure to Provide Required ADL Care
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living for one resident who was dependent on staff for personal care. R16 was admitted on 8/8/25, and the admission MDS dated 8/15/25 documented a BIMS score of 9, indicating cognitive impairment, with partial to moderate assistance needed for toileting. A CNA task flow sheet for 8/29/25 showed that bathing, toileting, and hygiene lacked evidence of completion for the resident. The facility’s investigation found that R16 did not receive incontinent care, turning and repositioning, or hydration until approximately 1:30 PM, about seven hours into the scheduled shift. The CNA reported that the resident was asleep in the morning and later acknowledged that incontinent care had not been provided before the resident was prepared for discharge after the family arrived. The investigation concluded that required resident care had not been provided.
Lack of Provider Acknowledgement of Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that a licensed pharmacist’s monthly medication regimen review included documented provider acknowledgement of irregularity recommendations for one resident. Review of the resident’s record showed physician orders for divalproex sodium 500 mg at bedtime for bipolar mood stabilization and buspirone 15 mg twice daily for anxiety. The monthly medication regimen reviews dated 10/7/25 and 1/8/26 each included recommendations to attempt dose reductions of divalproex and buspirone, respectively, but both review forms lacked the physician’s signature and any documentation showing the recommendations were reviewed. During interview, the DON stated the expectation was for the provider to complete and sign the MRR recommendation form and document any medication changes in the EMR, and the DON confirmed the forms were not signed and the provider progress notes did not show acknowledgement of the recommendations.
Failure to Ensure Blood Sugar Monitoring for Resident on Insulin
Penalty
Summary
A deficiency was identified when a resident with diabetes mellitus, admitted to the facility and prescribed both Humalog and insulin glargine, did not have a physician's order for blood sugar monitoring documented in the electronic medical record (EMR). Interviews with nursing staff and a nurse practitioner confirmed that standard practice is to obtain orders for finger stick blood sugar monitoring when a resident is receiving insulin, typically for at least three days upon admission. Despite this protocol, the EMR for this resident lacked any such order, and staff acknowledged the omission during interviews. The absence of a blood sugar monitoring order was confirmed through both record review and staff interviews.
Lack of Informed Consent Documentation for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was fully informed and understood their health status, care, and treatments when multiple psychotropic medications were initiated without documented discussion of risks and benefits. The resident was admitted on 9/12/24 and had an admission MDS on 9/18/24 showing a BIMS score of 6, indicating severe cognitive impairment. Subsequent physician orders included buspirone 5 mg by mouth every morning and at bedtime for anxiety on 2/13/25, lorazepam 0.5 mg by mouth every six hours for generalized anxiety disorder for 14 days on 3/3/25, and haloperidol 5 mg/mL intramuscularly every four hours as needed for agitation on 3/9/25. During interviews, an RN (E11) stated the facility’s expectation was to review each new psychotropic medication’s risks versus benefits with the resident if cognitively intact or with the resident’s representative, and that a specific form was used for these discussions. Another RN (E6) confirmed that the resident’s medical record lacked a Psychotropic Medication Administration Disclosure form for buspirone, haloperidol, and lorazepam (Ativan), and that the physician’s progress notes also lacked documentation of risk-versus-benefit discussions for these medications. These findings were later reviewed with the NHA, DON, and corporate representative.
Failure to Apply 14-Day Limits and Rationale for PRN Psychotropic Medications
Penalty
Summary
The facility failed to limit PRN psychotropic medications to 14 days for one resident when a PRN haloperidol injection and a PRN lorazepam tablet were ordered without appropriate 14‑day stop dates. The resident was admitted on 9/12/24 and had a quarterly MDS on 3/6/25 documenting a BIMS score of 9, indicating moderate cognitive impairment. On 3/9/25, a physician ordered haloperidol 5 mg/mL IM every four hours as needed for agitation with an indefinite stop date, and on 3/31/25, a physician ordered lorazepam 0.5 mg by mouth every six hours as needed for generalized anxiety disorder for 180 days. During interviews, the RN and the NHA stated that the facility’s expectation was that all PRN medications have a 14‑day stop date so the provider can evaluate usage, and both confirmed that the haloperidol and lorazepam orders did not have the required 14‑day limitation. The RN and NHA also confirmed that the physician’s progress notes lacked documentation of a rationale to extend the PRN lorazepam order to 180 days, despite the resident not using the medication consistently. These findings were confirmed with facility leadership, including the NHA, DON, and corporate representative, and the NHA acknowledged that the resident’s record did not contain evidence supporting the extended PRN lorazepam order beyond the standard 14‑day period.
Delayed Initiation of Antibiotic Therapy for Residents With Positive Urine Cultures
Penalty
Summary
The deficiency involves the facility’s failure to timely initiate antibiotic therapy for residents who met minimum criteria for treatment of urinary tract infections (UTIs) based on positive urine cultures. One resident with a thoracic spinal cord injury and an indwelling urinary catheter had a urinalysis and urine culture obtained after reporting urinary discomfort. The hospital lab received the specimen and, on the following day, reported abnormal urinalysis findings including cloudy urine, moderate blood, positive nitrates, and large white blood cells, along with an E. coli count greater than 100,000 cfu/ml, which was filed to the resident’s chart as a positive urine culture. Susceptibility results were filed the next day. Despite these findings, the facility did not obtain an order for antibiotic therapy until two days after the positive culture and abnormal urinalysis results were available, even though the resident met the minimum criteria for initiating antibiotics as a catheterized resident. A second resident with spastic quadriplegia cerebral palsy had a urinalysis and culture ordered for altered mental status. The urine specimen was obtained and received by the lab the same day, and the next day a faxed lab report showed a Proteus mirabilis colony count greater than 100,000 cfu/ml, indicating a positive urine culture. Culture sensitivity results were reported to the facility the following morning. However, an antibiotic order was not documented until later that same day, resulting in a delay in initiating antibiotic therapy after the resident had already met the minimum criteria for treatment as a non-catheterized resident. Interviews with nursing and lab staff confirmed that lab results are faxed or uploaded to the chart and that any nurse can contact the physician with results, but in both cases antibiotics were not started when the positive culture criteria were first met.
Failure to Follow Weekly Oxygen Tubing Change Orders
Penalty
Summary
A resident admitted with COPD and centrilobular emphysema had a physician’s order dated 7/20/24 for oxygen tubing to be changed weekly on Wednesday evenings, with each component labeled with the date and staff initials. On 6/5/25 at 10:34 AM, surveyors observed the resident’s continuous oxygen tubing labeled with a date of Saturday, May 24, 2025, and nebulizer tubing labeled with a date of Thursday, May 29, 2025. A subsequent observation at 3:15 PM on 6/5/25 showed the continuous oxygen tubing label dated Thursday, June 5, 2025. During an interview at 3:18 PM, an LPN stated she had changed the continuous oxygen tubing at the start of her 3 PM–11 PM shift on June 5, 2025, and confirmed the nebulizer tubing was still dated May 29, 2025 and should have been changed. The facility thus changed the resident’s continuous oxygen tubing after 11 days instead of weekly as ordered, and did not change the nebulizer tubing per the weekly order, failing to follow the physician’s plan of care for respiratory equipment maintenance. Findings were reviewed with the nursing home administrator, DON, and corporate representative on 6/12/25 at 12:45 PM.
Improper Admission Assessments by LPNs and SW
Penalty
Summary
The facility failed to adhere to the Delaware Board of Nursing Scope of Practice by allowing Licensed Practical Nurses (LPNs) and a Social Worker (SW) to complete admission assessments for four residents. According to the Delaware State Board of Nursing, only a Registered Nurse (RN) is authorized to perform initial admission assessments. The clinical records of residents R2, R11, R76, and R100 revealed that LPNs conducted various assessments such as Elopement Evaluation, Bed Rail Evaluation, Clinical Admission, Braden Scale Evaluation, and Lift Transfer Evaluation, which should have been completed by an RN. Additionally, for resident R76, a SW completed the Elopement Evaluation, further deviating from the required protocol. Interviews with the Director of Nursing (DON) and the RN Director of Utilization Management (UM) confirmed that the facility's practice was inconsistent with the regulatory requirements. The DON acknowledged that LPNs are not permitted to perform initial assessments, and the RN Director UM specified that several assessments, including admission, bed rail, Braden, incontinence, lift evaluation, AIMS, elopement, fall risk, and pain assessments, are expected to be completed by an RN at the time of admission. These findings were discussed with the Nursing Home Administrator (NHA) and the DON during the exit conference.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for staff, as evidenced by observations of standing water in the service area between the kitchen and ware washing room. Water was observed dripping from the ceiling near the interior hallway doors and the entrance to the ware washing room, with a mop bucket placed under one of the dripping areas. During an interview, the Nursing Home Administrator (NHA) confirmed the presence of the dripping and standing water, explaining that the water originated from a second-floor shower room, passed through a manager's office on the first floor, and dripped into the service area on the ground floor. These findings were reviewed with the NHA and the Director of Nursing (DON) during the exit conference.
Failure to Update Care Plan for Hearing Aid Use
Penalty
Summary
The facility failed to update and revise the care plan for a resident, identified as R37, who was readmitted to the facility from the hospital. Despite a quarterly MDS assessment indicating the use of a hearing aid, and an order for the insertion and removal of hearing aids, the care plan was not updated to reflect the resident's refusal to wear the hearing aids. Interviews with staff, including a CNA and an LPN, revealed that the resident often did not wear the hearing aids, preferring to remove them, which was not documented in the care plan. On multiple occasions, staff confirmed that the resident was not wearing the hearing aids, and the care plan did not address this issue. The RN-UM acknowledged that the care plan had not been revised to include the resident's refusal to wear the hearing aids. The NHA also confirmed that the care plan was not updated, and the deficiency was discussed with the NHA and DON during the exit conference.
Failure to Re-evaluate PRN Medication Order for Anxiety
Penalty
Summary
The facility failed to ensure that a PRN medication order for anxiety was re-evaluated after 14 days for one resident. The resident was admitted to the facility on March 4, 2024, and on March 18, 2024, a physician's order was entered for clonazepam, a controlled drug, to be administered as needed for anxiety, up to three times a day. However, there was no evidence that this PRN order was re-evaluated by a provider after 14 days of being ordered, as required. During an interview, a medical doctor (E4) acknowledged that typically a new PRN order for an anti-anxiety medication is evaluated 14 days after initiation, but this was not done in this case. The findings were discussed with the Nursing Home Administrator (E1) and the Director of Nursing (E2) during the exit conference.
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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 Seaford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willowbrooke Court Skilled Center At Manor House | 0.2 mi | ★★★★★ | 1 | 0 |
| Seaford Center | 0.4 mi | ★★★★★ | 0 | 0 |
| Delaware Bay Rehabilitation And Healthcare Center | 11.9 mi | ★★★★★ | 0 | 0 |
| Delmar Nursing & Rehabilitation Center | 13.1 mi | ★★★★★ | 6 | 1 |
| Ocean Grove Post Acute | 17.3 mi | ★★★★★ | 11 | 0 |
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