Citations in Delaware
Statistics, citations and compliance trends for long-term care facilities in Delaware.
Statistics for Delaware (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in Delaware
A facility failed to provide required supervision and assistance during transfers and bed mobility for two residents. One resident who was completely dependent and required a Hoyer lift with assist of 2 fell when a CNA used the wrong sling and did not have a second staff member present, resulting in head trauma, brain bleeds, and skull fractures. Another resident who required assist of 2 for bed mobility fell from the bed during toileting care when one CNA worked alone.
Failure to Report Allegation of Neglect Involving Improper Hoyer Lift Transfer: A resident with dementia, stroke, and ESRD who was fully dependent for transfers slipped out of a Hoyer lift during a transfer and sustained a head injury. The incident was reported to the State as a fall with injury, but the DON knew the CNA used the wrong sling for the wrong lift and did not have a second staff member present, and the report did not identify the event as an allegation of neglect.
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 supervise a resident at risk for elopement: A newly admitted resident with baseline confusion, poor safety awareness, and a low BIMS score was identified as a wander risk and placed on a Wanderguard, yet the resident exited through double doors without staff knowledge. Video showed the resident walking unattended along a busy roadway while the wander system did not alarm, and the resident was later found by a staff member and returned.
A resident with severe cognitive impairment, fall risk, and need for assistance to roll fell from the bed during in-bed care when a CNA instructed the resident to roll and the resident rolled the opposite way. The resident was found face down beside the bed with facial bleeding and skin tears, was sent to the ER, and later returned with stitches to the cheek. The facility’s investigation noted positioning near the bed edge, insufficient guarding, a bed that was not wide enough, and no floor mat in use during care.
An LPN documented a resident's unwitnessed fall, baseline and subsequent neurochecks, and a nursing note, but the record lacked evidence that an RN completed the required initial post-fall assessment and documentation. The resident was on Eliquis for aFib and was sent to the ER after being found on his knees with his head resting on the bedside table.
Failure to Provide Required Two-Person Assistance and Correct Mechanical Lift Equipment
Penalty
Summary
The facility failed to ensure adequate assistance and supervision during transfers and bed mobility for two residents who required extensive staff support. One resident had diagnoses including dementia, stroke, and end-stage kidney disease, was severely cognitively impaired with a BIMS score of 00, and was completely dependent on staff for transfers. Her care plan required a Hoyer lift with assist of 2 for transfers. During a transfer from a wheelchair to bed, a CNA used a Hoyer lift with the wrong sling and did not have a second staff member present. The resident slipped out of the lift and fell to the floor, sustaining a head injury and later being diagnosed with multiple brain bleeds and skull fractures. The CNA stated he had been a CNA for three months, this was his first job, and it was the first time he had worked with the resident. He said he checked the resident’s transfer status, saw that she needed a Hoyer lift, and obtained a sling from storage, but did not know it was not the correct sling for that lift. The DON stated the facility had two types of Hoyer lifts with two different sling types, and the investigation found that the CNA used the sling that hooks on the lift instead of the one that snaps into place. The DON also confirmed that a second staff member was not present during the transfer. A second resident had diagnoses including hemiplegia and hemiparesis following cerebrovascular disease, was cognitively intact with a BIMS score of 14, and required a Hoyer lift with assist of 2 for transfers and assist of 2 for bed mobility. During toileting and bowel care, one CNA performed care alone even though the resident was a two-person assist. The CNA stated she knew the resident required two staff, but she was the only CNA on the unit and believed she could manage the resident alone. While providing care, the resident rolled away and fell from the bed to the floor and was sent to the ED.
Failure to Report Allegation of Neglect Involving Improper Hoyer Lift Transfer
Penalty
Summary
The facility failed to identify and report an allegation of neglect involving a resident who required a Hoyer lift for transfers with assist of 2 and who was completely dependent on staff for transfers. The resident had diagnoses including dementia, stroke, and end-stage kidney disease, and a BIMS score of 00 on the annual MDS, indicating inability to complete the cognitive assessment. During a transfer, the resident slipped out of the Hoyer lift and fell to the floor with the sling underneath her, resulting in a bump to the posterior head and transfer to the ED after the husband requested emergency evaluation. Facility documentation and staff interviews showed that the incident was reported to the State as a fall with injury, but the report did not identify the known transfer error or the unsafe staff actions involved. The DON stated that immediately after the incident she knew the CNA used the wrong sling for the wrong Hoyer lift and did not have a second staff member present during the transfer. Although the NHA and DON were aware of these circumstances, the incident report remained vague and did not disclose the incorrect transfer, the lack of required two-person assist, or the event as an allegation of neglect.
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 Supervise a Resident at Risk for Elopement
Penalty
Summary
A newly admitted resident with diagnoses including traumatic subarachnoid hemorrhage was identified on admission as an elopement risk due to baseline confusion, poor safety awareness, and independent ambulation. The resident’s clinical record documented a wander risk evaluation, a request for a Wanderguard, and placement of the device on the resident’s left ankle. The resident was also noted to have a BIMS score of 6 and was assessed as independent but at increased risk for elopement. Despite the resident being identified as a wander risk and wearing a Wanderguard, the resident exited the facility through double doors without staff knowledge or supervision. Video surveillance showed the resident leaving the building and walking unattended along a main traffic roadway with a posted speed limit of 45 miles per hour for approximately 0.5 to 1 mile. The wander management system did not activate or alert staff, and the resident was found outside near the road by a staff member and returned to the facility.
Inadequate Supervision During In-Bed Care Led to Resident Fall
Penalty
Summary
The facility failed to ensure adequate assistance and supervision to prevent an accident for one resident who required moderate assistance. The resident was admitted with congestive heart failure and cognitive communication deficit, had a care plan identifying fall risk due to chronic pain and weakness, and a readmission MDS showing a BIMS score of 5 with severely impaired cognition, upper extremity impairments, and need for partial to maximal assistance to roll left and right. The resident was also receiving Apixaban 5 mg twice daily for DVT. During morning care, a CNA was providing in-bed care and instructed the resident to roll, but the resident rolled the opposite way and fell from the bed to the floor. Staff found the resident prone beside the bed with blood flowing from the face, along with a skin tear to the left cheek and skin tears to the right elbow and both knees. The resident was sent to the ER and later returned with 5 stitches to the cheek. The facility’s investigation documented that the resident had been positioned near the bed edge, the bed was not wide enough, guarding was insufficient, and a floor mat was absent during care.
Missing RN Post-Fall Assessment After Resident Fall
Penalty
Summary
The facility failed to meet professional standards of quality for one resident reviewed for falls by not having an RN complete and document the required RN post-fall assessment after an unwitnessed fall. The report states that Delaware Board of Nursing Scope of Practice requires an RN to perform the initial fall assessment, while an LPN may complete subsequent assessments. In this case, the resident had a physician's order for Eliquis twice daily for atrial fibrillation, and the resident was found on his knees with his left arm inside the bedside table drawer and his head resting on the bedside table before being sent to the ER. The clinical record showed that an LPN documented the incident report, baseline and subsequent neurological checks, and a nursing note stating the resident had no injuries, but the record lacked evidence that an RN performed the post-fall assessment and documentation. During interview, the LPN recalled the fall and confirmed she completed the baseline and subsequent neurochecks, but she could not state whether an RN assessed the resident after the unwitnessed fall. The DON, ADON, and ED were later informed of the finding during interviews and the exit conference.
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Compliance trends in Delaware
Data through May 2026Comparisons below measure the most recent period Jun 2025 – May 2026 against the prior period Jun 2024 – May 2025 (two equal 12-month windows). The most recent 2 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 2-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 2 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025; the most recent 2 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 2 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
No tags meet the emerging criteria for this period — nothing rare is spiking right now.
Trusted data from CMS and state health departments
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