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 Delaware Court Health Care Center during CMS and state inspections, most recent first.
The facility failed to adequately address repeated resident council concerns about limited snack variety and consistently cold food. Over many months, residents with various medical conditions, including dementia, CKD, pulmonary disease, and dysphagia, repeatedly reported that snacks lacked variety and that meals were often served cold in both rooms and the dining area. Concern forms generated from council meetings were incomplete or failed to address all issues raised, and residents stated they were not offered additional snack options or information on available items. The Activity Director confirmed that these concerns were ongoing and frequently reported, while also acknowledging a lack of knowledge about any effective actions taken to resolve the problems, despite a policy requiring written administrative responses to council concerns.
Surveyors found that multiple PTAC units in resident rooms and a private dining room were improperly sealed, leaving visible gaps to the outside that allowed cold air and, in at least one room, water intrusion. Staff and residents confirmed feeling cold air, observing peeling wallpaper with a dark substance behind it, and using towels to absorb incoming water. One resident reported having complained several times without resolution, and another linked the gaps to bugs in the room. The maintenance supervisor acknowledged prior notice of at least one room’s PTAC problem and stated that proper correction would require removing and reinstalling the unit, while the administrator confirmed there were no documented maintenance work orders despite a policy requiring such documentation.
Staff did not consistently monitor or maintain proper holding temperatures for hot foods during a lunch meal service. A dietary staff member reported that only cooking temperatures, not holding temperatures, were taken, and surveyor checks found items on the steam table either excessively hot or below the facility’s hot-holding standard. A test tray assembled by the kitchen manager showed substandard temperatures before leaving the kitchen and further cooling after being transported on a non-insulated cart to a hallway without a warming cart, resulting in food that tasted cold. These practices did not follow the facility’s policy requiring temperature checks throughout meal service and maintenance of hot foods at or above 135°F using appropriate equipment.
The facility failed to ensure puree food was prepared to the correct smooth, pudding-like consistency for several residents with dysphagia, malnutrition, neurologic conditions, and dementia who had orders for puree diets. A dietary staff member was observed pureeing breaded salmon patties with broth in a mixer, wiping the sides with a gloved hand, scraping food from the glove back into the mixer, and then using the same glove to handle a broth container. The puree remained with visible chunks of salmon and breading and did not meet the facility’s stated standard of mashed potato or pudding-like consistency, despite the staff member acknowledging the presence of distinct pieces and proceeding with the product as the final puree.
Surveyors found that the facility failed to store and label food safely, with multiple uncovered, unlabeled, and undated items in dry and cold storage, and thawed products that were labeled to be kept frozen. Dietary staff did not follow proper hand hygiene or glove-use practices while preparing pureed foods, checking food temperatures, and serving on the tray line, including using gloved hands to scrape mixers, handle containers and equipment, and place thermometers and fingers into multiple food items without changing gloves or washing hands. Overhead vents above food preparation and service areas were heavily dust-laden, and dust was reported to be blowing over food preparation areas, affecting all residents who consumed food from the kitchen.
The facility failed to keep two residents’ medication regimens free from unnecessary drugs and failed to order pain meds with clear parameters. One resident with dementia and other chronic conditions had duplicate acetaminophen orders without a max daily dose, and vitamins were ordered with sepsis as the diagnosis. Two residents had acetaminophen, Norco, and oxycodone orders without parameters, and MAR review showed repeated administration based on pain scores, including opioid use for low pain ratings and acetaminophen for higher pain ratings.
A resident’s PASARR was not updated after new mental illness diagnoses were added. The resident had dementia, major depressive disorder, generalized anxiety, and delusional disorders, and the existing PASARR incorrectly indicated no mental disorder diagnosis. The DON confirmed the PASARR should have been updated.
Failure to Hold Required Quarterly QA Meetings: The facility did not ensure QA meetings occurred quarterly as required. QA meeting notes showed meetings were held earlier in the year, but there were no QA meetings documented for the last quarter of the year. Monthly QAPI meetings were held, but the medical director did not participate in those meetings and only attended the quarterly QA meetings, as confirmed by the Interim DON, Administrator, and Regional Clinical Director.
The facility failed to maintain clean and sanitary shower rooms, affecting all residents. Observations showed black-spotted substances along grout lines and tiles in all four shower rooms, with additional issues like deteriorating fabric on a shower chair. An interview with a housekeeper revealed uncertainty about the cleaning schedule, and the facility could not provide documentation to confirm weekly cleaning as required by policy.
Failure to Address Repeated Resident Council Concerns About Snacks and Food Temperature
Penalty
Summary
The deficiency involves the facility’s failure to adequately address and respond to recurring concerns raised in resident council meetings regarding snack variety and food temperatures, affecting four cognitively intact or impaired residents with multiple medical conditions, including atrial fibrillation, pulmonary disease, dementia, chronic kidney disease, vascular disease, and dysphagia. Resident council minutes over approximately a one‑year period documented repeated complaints about limited snack options and cold food at meals. Despite these concerns being voiced at multiple meetings, the corresponding concern forms were incomplete or failed to address all issues raised. For example, some forms did not mention food temperature concerns at all, others only partially addressed snack variety, and some did not address either the lack of snack variety or cold food. Residents reported that they had asked for more variety in chips and fruit and had not been offered choices or a list of items available from the supplier, and they stated that the facility gave excuses for the continued reliance on peanut butter sandwiches. Residents also reported that food was consistently served cold both in their rooms and in the dining room. The Activity Director confirmed that resident concerns were documented in council minutes and that concern forms were written and given to department heads, but acknowledged that residents had consistent, repeated concerns about snack variety and cold food over the majority of the months reviewed. The Activity Director denied knowledge that the requested variety of snacks was ever offered, denied knowledge of what the facility was doing to improve food temperatures, and was unaware of any test trays being completed or results shared with residents. The facility’s own policy stated that administration shall respond in writing to concerns and recommendations raised by the resident council, yet the repeated, unresolved complaints and incomplete concern forms demonstrated that resident council concerns were not consistently or effectively addressed.
Unsealed PTAC Units Allow Cold Air and Moisture Into Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not maintaining properly sealed Packaged Terminal Air Conditioner (PTAC) units in multiple resident rooms and a private dining room during very cold weather. A tour showed that each resident room and the private dining room had a PTAC unit installed under the window, and in several locations there was approximately a 1/4 inch gap between the unit and the wall, open to the outside, allowing cold air to enter. This condition was observed in the resident private dining room and in the rooms of six residents, where the units did not span the wall opening completely. In one room shared by two residents, the PTAC unit was not sealed around the entire unit, and staff confirmed that cold air was coming through the gap. On the right side of that unit, wallpaper was peeling from the wall from the top of the unit to the baseboard, exposing a dark substance on the wall and the back of the wallpaper. A white bath towel was rolled up under the PTAC unit. One of the residents in that room stated she could feel the cold air and explained that the towel was used to soak up water coming in from outside elements. She reported having notified administration several times about the problem without results. In another resident room, the exposed wood around the PTAC unit appeared wet and black, as if damaged, and staff verified these observations. Additional observations in other resident rooms showed similar 1/4 inch openings between the PTAC units and the walls, with cold air entering and wallpaper beginning to peel near the baseboard. One resident associated the gap with having bugs in the room. The Maintenance Supervisor stated he was responsible for checking PTAC units and sealing areas where cold air entered with silicone, but he reported being unaware of cold air coming through the units until the survey. He acknowledged that the problem with one room’s PTAC unit had been reported to him in the fall of 2025 and that correcting the issue would require removing and reinstalling the unit from the wall and outside. The Administrator confirmed there were no Maintenance Work Order Request Forms for the PTAC units or for wallpaper separating from the walls, despite the facility’s policy requiring all maintenance requests to be documented on a work order form for tracking and timely resolution.
Failure to Maintain Safe and Palatable Food Temperatures During Meal Service
Penalty
Summary
Facility staff failed to ensure that food was served at safe and palatable temperatures during a lunch meal service. During observation in the dining room, about half of the residents had already been served when a dietary staff member reported that they took cooking temperatures but not holding temperatures. Surveyor temperature checks of items on the steam table showed green beans at 184°F, mashed potatoes at 178°F, burger patties at 120°F, salmon patties at 74°F, and potatoes at 146°F. After surveyor intervention, the burger and salmon patties were returned to the oven. The dietary staff member stated that if the puree food had not taken so long, the food would not have been outside the required temperatures. The kitchen manager later stated the goal temperature for food held on the steam table was 150°F. Further observation of a test tray revealed that holding temperatures in the kitchen before plating were already below the facility’s hot-holding standard of 135°F, with the salmon patty at 119.5°F, potatoes at 106°F, and green beans at 139°F. The tray was then placed on a non-insulated cart and transported to a resident hallway that did not have a warming cart, only a metal rack, despite the facility having plate warmers and three insulated carts used elsewhere. After tray delivery, the test tray food temperatures dropped further, with the salmon patty at 106°F, potatoes at 96°F, and green beans at 109°F, and the food was described as tasting cold. The kitchen manager declined to taste the food and confirmed it would be cold. Review of the facility’s “Holding Food Temperatures and Guidelines” policy showed that it required serving line temperatures to be taken at the beginning, middle, and end of meal service, and that hot foods should be held at 135°F or higher using methods such as a proper steam table and heated plates, which was not followed in this instance.
Improper Preparation and Consistency of Puree Diets
Penalty
Summary
The deficiency involves the facility’s failure to provide puree food in the correct consistency for multiple residents with physician orders for puree diets. Six residents with diagnoses including cerebral infarction, respiratory failure, protein malnutrition, dysphagia, Parkinson’s disease, hemiplegia, hemiparesis, Alzheimer’s disease, dementia, malnutrition, heart disease, failure to thrive, pulmonary disease, and vascular disease were ordered puree texture food. Their cognitive status ranged from intact to impaired, as reflected by BIMS scores from 0 to 15. Facility policy for puree diets, dated 2022, specified that this diet is for residents who cannot chew or have difficulty swallowing and that the sides of the blender shall be scraped and processed until the food is smooth like pudding. During an observation and interview with a dietary staff member, the surveyor observed the preparation of puree food for residents on puree diets. The staff member placed three breaded salmon patties into a roboku mixer and added chicken broth one spoonful at a time, for a total of eight spoonfuls, then added additional unmeasured broth. On three occasions, the staff member wiped the sides of the mixer with a gloved hand, scraped the food from the glove onto the edge of the mixer, and then, with the same gloved hand, grabbed a jar of broth to add more liquid. Several chunks of salmon and breading remained visible on the sides of the mixer and were not fully mixed back in. The completed puree, when taste tested, was found to contain small chunks and distinct pieces rather than the intended mashed potato or pudding-like consistency. The dietary staff member acknowledged that the mixture contained chunks and distinct pieces and stated it was the best consistency they were going to achieve, despite the facility policy requiring a smooth, pudding-like texture.
Food Storage, Hand Hygiene, and Kitchen Sanitation Deficiencies
Penalty
Summary
Surveyors identified that the facility failed to store and label food in a safe and sanitary manner and did not follow its own food storage policies. During a morning observation, multiple food items in the kitchen were found uncovered, unlabeled, and undated, including a bowl of cookies in envelopes, a tray of uncovered cookies on a prep table, three foil-wrapped sandwiches in the refrigerator, a large metal bowl of fajita mix, an open bag of vanilla wafers, thawed chocolate magic cups labeled to be kept frozen, six cups of yogurt, a red bowl with an unknown substance, an open bottle of water, and several cups of pre-poured juices and milk. The kitchen manager confirmed that these items should have been covered, labeled, and dated, and facility policies required dry and cold storage areas to be maintained to keep food safe and free from contamination, with opened packages stored in sealed containers and all items labeled and dated. Surveyors also observed multiple failures in hand hygiene and glove use during food preparation, temperature checking, and tray line service, as well as unsanitary kitchen conditions. One dietary staff member preparing pureed salmon patties repeatedly reached a gloved hand into a mixer to scrape the sides, then used the same gloved hand to handle a broth jar and blender controls without performing hand hygiene or changing gloves, and reported staff had been instructed to use their hands rather than utensils for scraping. Another dietary staff member taking food temperatures stuck gloved fingers into baked beans, used those fingers to wipe the thermometer, then used a sanitizer wipe and, without changing gloves or performing hand hygiene, placed the thermometer into salmon patties and potatoes, confirming that his gloves became soiled and were not changed. During tray line service, a dietary staff member handled a roll and then, without changing gloves, used his hands to grab other food items for trays. Additionally, overhead vents above food preparation and service areas were observed to have a thick layer of dust, and the kitchen manager confirmed the vents were dirty and dust was blowing above food preparation areas. These issues affected all residents who consumed food from the kitchen, except one resident who did not eat food from the kitchen.
Unnecessary Medications and Missing Pain Medication Parameters
Penalty
Summary
The facility failed to ensure that residents’ drug regimens were free from unnecessary drugs by not documenting proper indications and maximum dosage parameters for several medications. For one resident with dementia, cerebral infarct, fractured tibia, malnutrition, vascular disease, and osteoporosis, physician orders included two separate acetaminophen orders, one for fever and one for pain, but neither order included a maximum daily dose or a statement not to exceed a specific amount in 24 hours. The same resident also had orders for ascorbic acid and cholecalciferol with sepsis listed as the diagnosis, and the regional nurse confirmed sepsis was not an appropriate diagnosis for those vitamins. The facility also failed to ensure pain medications were ordered with parameters and administered appropriately for two residents. One resident had orders for acetaminophen and Norco, and the orders did not include parameters to guide staff on when to administer one medication versus the other. The medication administration record showed acetaminophen and Norco were administered on multiple occasions for documented pain scores, and the regional nurse confirmed the orders should have included parameters and a maximum amount or daily limit. The same resident’s pain regimen included repeated use of opioid and non-opioid analgesics without the order details described in the record. A second resident with hemiplegia and hemiparesis, COPD, diabetes, cerebral infarction, paralytic syndrome, and dysphagia had orders for acetaminophen and oxycodone that also lacked parameters for use. The MAR showed frequent administration of oxycodone across January and February 2026 for a wide range of pain scores, including scores of zero and three, and acetaminophen was also given for pain scores documented in the record. The regional nurse confirmed no pain medication parameters were in place and acknowledged that high pain scores were treated with acetaminophen and low pain scores were treated with oxycodone.
PASARR Not Updated After New Mental Illness Diagnosis
Penalty
Summary
The facility failed to ensure an updated Preadmission Screening and Resident Review (PASARR) was completed when a resident was diagnosed with a new mental illness diagnosis. Resident #53 was admitted on 05/29/2020 and had diagnoses including dementia, major depressive disorder, generalized anxiety, and delusional disorders. The resident’s quarterly MDS 3.0 assessment showed a BIMS score of 12 out of 15, indicating moderately impaired cognition for daily decision-making abilities. Review of the electronically uploaded PASARR dated 03/11/2020 showed that the question asking whether the resident had a diagnosis of any mental disorders was marked “no.” During interview on 09/30/2025 at 2:13 P.M., the DON confirmed the PASARR was not updated and should have been with the newly added mental illness diagnosis.
Failure to Hold Required Quarterly QA Meetings
Penalty
Summary
The facility failed to ensure that Quality Assurance (QA) meetings occurred quarterly as required. Review of the QA meeting notes showed the committee met on 10/15/24, 1/21/25, 4/15/25, and 7/22/25, but there were no quarterly meetings held during the last quarter of 2025. The documentation also showed this was the meeting at which the medical director participated at the facility. Review of the facility records showed monthly Quality Assurance Performance Improvement (QAPI) meetings were held, but the medical director did not participate in those meetings. During interviews on 02/09/26, the Interim DON confirmed there were no QA meeting notes showing a meeting in the last quarter of 2025. The Administrator and Regional Clinical Director confirmed the medical director did not attend the QAPI meetings and only attended the quarterly QA meetings. The facility's QAPI plan dated 5/23/25 stated the QAA committee would include department managers, the administrator, DON, infection control nurse, medical director, and consulting pharmacist, and that the QAA committee would meet monthly.
Facility Fails to Maintain Clean Shower Rooms
Penalty
Summary
The facility failed to maintain its shower rooms in a clean and sanitary condition, impacting all residents who used them. Observations revealed that all four shower rooms contained black-spotted substances along the grout lines and tiles, particularly at the bottom of the walls beneath the shower heads and in the corners. Additionally, the shower chair in the 100's shower room had deteriorating fabric with black-spotted substances and hair. These conditions were observed multiple times throughout the day, indicating that the shower rooms had not been cleaned as required. An interview with Housekeeper #114 confirmed that the shower areas should be cleaned weekly and as needed, but the housekeeper was unsure if they had been cleaned that week. The facility was unable to provide documentation to confirm that the cleaning had been completed weekly, as per their policy. This deficiency was investigated under Complaint Number OH00158584.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
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