Citations in Delaware
Comprehensive analysis of citations, statistics, 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
Surveyors found that shower rooms on multiple floors had cracked and broken tiles, standing water, dripping shower heads, discolored walls, and clutter that blocked access to handwashing sinks, as confirmed by CNAs who reported difficulty washing hands due to equipment stored in these areas. Hallway carpets and several residents’ room floors were repeatedly observed to be visibly soiled, and the ESD acknowledged there was no established carpet-cleaning schedule. Additionally, a shower bed cushion with multiple surface openings exposing permeable foam was left in use for an extended period, with staff confirming its damaged condition and the inability to properly disinfect it.
The facility failed to follow professional standards and state scope-of-practice requirements by allowing LPNs to complete admission assessments and initial post-fall assessments that must be performed by an RN, and by not ensuring RN involvement in discharge education. In two separate admissions, an LPN completed the full admission nursing assessment and related evaluations instead of an RN. For another resident, the discharge plan was documented by non-licensed staff, and there was no evidence in the record that an RN provided or documented discharge teaching. In a fall event involving a resident with dementia and cancer, an LPN completed the initial neurological and post-fall assessment, with no RN assessment documented.
A resident who was totally dependent on staff for ADLs due to a stroke was care planned to receive regular showers or bed baths according to his preferences and to follow a twice-weekly bathing schedule. Review of documentation showed that, over multiple scheduled opportunities, the resident was bathed only twice, refused once, and on two scheduled days no bath or shower was provided and no reason was documented in the record for the missed care. Progress notes lacked any explanation for these missed bathing events, and facility leadership confirmed the documentation gaps during the survey.
A cognitively intact resident with orthostatic hypotension and heart failure reported that a male CNA entered the room without knocking or announcing himself and attempted to remove the resident’s underwear while the resident was asleep in order to check for incontinence. The resident described feeling tugging at the hip and being told he had to take his underwear off, though he denied any sexual touching. Surveyors determined that staff attempted to provide incontinence care without first waking the resident or obtaining permission, resulting in a failure to maintain the resident’s dignity and right to self-determination.
A resident with dementia and impaired cognition, who had an order for 0.25 mL (5 mg) concentrated morphine sulfate solution PRN for pain and a separate order for 15 mg MS Contin tablets, received a massive overdose when an LPN misinterpreted 15 mg as 15 mL and administered 15 mL of the liquid morphine instead of 0.25 mL. The LPN reported relying on the MAR display of 15 mg and, after asking a supervisor a general question about narcotic administration, proceeded to give the incorrect volume. The error was recognized at shift change, and documentation by nursing and the medical director confirmed that the resident received 300 mg instead of 5 mg, requiring two doses of naloxone to reverse the overdose and leading surveyors to cite an immediate jeopardy deficiency for a significant medication error.
Two residents reported that CNAs were rough during care and, in one case, that clothing was torn. In both situations, staff received the abuse allegations but did not ensure they were reported to the state agency within the facility’s required two-hour timeframe. Leadership later confirmed awareness of the policy requirement and acknowledged that the reporting timeframes were not met.
Surveyors found that chicken salad sandwiches were not maintained at proper cold holding temperatures during meal service. A pan of approximately 20 sandwiches was observed on the counter near the steam table and used on the tray line, and temperature checks by the Dietary District Manager showed the chicken salad at 54°F. A second tray of sandwiches taken from the refrigerator measured 57°F. The chicken salad, made from diced cooked chicken, mayonnaise, and pepper, was required by facility policy to be held below 41°F. This deficient practice had the potential to affect most residents in the facility.
The facility failed to report an allegation of resident-to-resident abuse to the state agency as required by its abuse policy. A cognitively intact resident, as shown by a high BIMS score on a recent MDS, struck a severely cognitively impaired resident in the face while lying in bed, as documented in progress notes and risk management records and confirmed by an LPN. The cognitively impaired resident had a very low BIMS score on a recent MDS and was attempting to calm or comfort the other resident at the bedside when struck. The DON and a regional corporate consultant confirmed the incident was not reported to the state agency, and the Administrator stated he believed the event was accidental, despite the written policy requiring all alleged violations and substantiated incidents to be reported.
The facility failed to thoroughly investigate an allegation of potential abuse when a cognitively intact resident struck a severely cognitively impaired resident in the face while that resident was attempting to provide comfort at the bedside. Documentation showed the incident was reviewed through internal risk management and deemed not state reportable, and the DON was notified, but there was no documentation of interviews with residents or staff as part of the investigation. This lack of investigative documentation did not follow the facility’s abuse policy, which requires a focused investigation into whether abuse occurred, assessment for injury, identification of causative factors, and interventions to prevent further injury.
A resident with a history of femur fracture developed acute shortness of breath and low oxygen saturation, but nursing staff failed to consistently assess, monitor, or document vital signs and did not promptly notify the provider or initiate emergency care. Despite observable respiratory distress and declining oxygen levels, interventions were delayed and inconsistently applied, resulting in the resident being transferred to the hospital unresponsive, where she later expired.
Failure to Maintain Clean, Accessible Shower Rooms and Resident Care Equipment
Penalty
Summary
Surveyors identified that the facility failed to maintain clean, sanitary, and home-like shower rooms and resident areas on the second, third, and fourth floors. During multiple tours, the second-floor shower room was observed with cracked tiles, standing water on the floor, discolored walls, and water dripping from the shower head. The handwashing sink in this room was inaccessible due to multiple pieces of equipment, including wheelchairs and mechanical lifts, and a large amount of black debris was seen in an area between the wall and window where a heater had previously been located. CNAs reported that they were not able to access the handwashing sinks in the shower rooms because of the amount of equipment stored there. Similar conditions were observed in the third- and fourth-floor shower rooms, including broken tiles, dripping shower heads, discolored walls, and inaccessible handwashing sinks due to wheelchairs and other equipment. Across all three units, hallway carpets and multiple residents’ room floors were repeatedly observed to be visibly soiled over several days, and the environmental services director stated there was no schedule for carpet cleaning. The shower rooms on all three units continued to be cluttered on repeated observations. In addition, a plastic cushion on a shower bed in the fourth-floor shower room was found with five to six surface openings exposing the underlying permeable foam. Staff interviews confirmed that the cushion had been in that condition for some time and that the openings were present, raising questions about how it could be disinfected. These findings regarding environmental cleanliness, clutter, and damaged resident care equipment were confirmed with facility leadership during the survey.
Failure to Use RNs for Required Admission, Discharge Teaching, and Post-Fall Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services were provided in accordance with Delaware State Board of Nursing scope of practice requirements and professional standards. For one resident admitted on 11/22/25, an LPN completed the Nursing Admission/Readmission/Annual/Significant Change Assessment, as well as the lift/transfer/reposition evaluation, AIMS assessment, PHQ-9 evaluation, and bedrail evaluation in the EMR, despite state regulations specifying that admission assessments must be completed by an RN. For another resident admitted on 6/27/25 with diagnoses including breast cancer and dementia, an LPN completed the Nursing Admission/Readmission/Annual/Significant Change Assessment and documented completion of the admission nursing assessment, with no evidence in the EMR that an RN performed the required admission assessment. The deficiency also includes failures related to discharge education and post-fall assessment. One resident admitted on 11/11/25 and discharged on 11/19/25 had a discharge plan documented entirely by a social work assistant and a nursing clerical assistant, with no evidence that any licensed nursing personnel reviewed the discharge plan documentation. EMR progress notes for this resident contained no evidence that an RN provided discharge education prior to discharge; instead, a social worker documented that the resident chose to discharge and was educated on the risks of not completing rehab. For the resident with breast cancer and dementia who experienced a fall on 7/8/25, a fall incident report and neurological evaluation flow sheet showed that an LPN completed the initial post-fall neurological assessment and documentation, even though state regulations require an RN to complete the initial post-fall assessment. Review of the EMR confirmed there was no RN post-fall assessment documented for this resident.
Failure to Provide Scheduled Bathing for Dependent Resident
Penalty
Summary
A dependent resident with an ADL self-care performance deficit related to a stroke was care planned on admission to be totally dependent on staff for bathing or showering, with an intervention specifying that it was very important for him to choose how he was bathed and that he preferred a shower or bed bath. The resident’s care plan also emphasized the importance of engaging in daily routines meaningful to his preferences. Documentation from admission through early September showed he was scheduled to receive a shower or bath twice weekly on the evening shift and as needed. Out of five scheduled bathing opportunities during the review period, the resident received bathing on two occasions and refused once, but there was no documentation explaining why bathing was not provided on two other scheduled dates. Review of the progress notes confirmed the lack of documented reasons for missed bathing on those dates, and the NE/IP later confirmed these findings during the surveyor interview.
Failure to Maintain Resident Dignity During Incontinence Care
Penalty
Summary
The deficiency involves a failure to ensure a resident’s right to dignity and self-determination during incontinence care. The resident was admitted with orthostatic hypotension and heart failure and had an admission MDS BIMS score of 15, indicating intact cognition. According to a facility incident report, the resident reported that a male CNA entered his room and pulled down his underwear or pants while he was in bed, with the resident later clarifying that he was woken up by the CNA attempting to pull his underwear down. The resident stated that the CNA did not announce himself, did not knock on the door, and that he felt tugging at his hip while he was asleep. The resident reported that the CNA told him he had to take his underwear off and that the CNA was trying to remove his underwear to check for incontinence, but the resident denied being touched in a sexual manner. The incident reports and subsequent interview with the resident consistently described that the CNA attempted to provide incontinence care without first waking the resident or obtaining his permission, and without announcing his presence or knocking before entering the room. These actions failed to honor the resident’s right to be treated with dignity and to exercise control over his personal care.
Significant Morphine Dosing Error Due to Misinterpretation of mg and mL
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when an incorrect dose of concentrated morphine sulfate oral solution was administered. The resident had dementia and a quarterly MDS showing moderately impaired cognition with a BIMS score of 10 and was receiving opioids for pain. The physician’s order in place directed that the resident receive 0.25 mL (5 mg) of morphine sulfate concentrate oral solution every three hours as needed for pain, and on a later date a new order was entered for MS Contin (morphine sulfate) 15 mg extended-release tablets by mouth twice daily for pain. On the morning of the incident, the assigned LPN administered 15 mL of the concentrated morphine sulfate solution instead of the ordered 0.25 mL dose. In a written statement, the LPN reported that the electronic system displayed an ordered dose of morphine 15 mg, while the bottle label stated 0.25 mL, and that after seeking clarification from a supervisor, she was told to follow the dose listed in the MAR. The LPN then incorrectly interpreted 15 mg as 15 mL and administered that amount. Another nurse later confirmed that she had previously worked with the resident, was familiar with the correct 0.25 mL PRN dose, and had left 17.25 mL of morphine sulfate concentrate in the bottle at the end of her prior shift, while the LPN reported having given 15 mL to the resident. The error was discovered during shift exchange when the outgoing nurse recognized the discrepancy between milligrams and milliliters. Nursing notes documented that the resident had received 15 mL of liquid morphine, and the medical director’s note confirmed that, given the concentration of 20 mg/mL, the resident received 300 mg instead of the prescribed 5 mg. The facility determined that the nurse failed to perform the rights of medication administration when she misinterpreted 15 mg as 15 mL, resulting in the resident receiving 59 times the ordered dose of morphine sulfate solution. The resident required administration of naloxone intramuscularly on two occasions to reverse the overdosage, and the situation was identified by surveyors as immediate jeopardy, past non-compliance.
Removal Plan
- Upon discovery of the medication error, R5 was immediately assessed and the physician was notified; a new order for Narcan (Naloxone) was obtained and administered; R5's responsible party and Hospice were notified; R5 was placed on alert charting to monitor vital signs and respiratory status.
- An audit was completed on residents with orders for liquid morphine and no other errors were identified.
- An audit of residents receiving controlled substances was completed to determine if any other residents had orders for the same medication in two different forms and no other residents were identified.
- The facility conducted a root cause analysis.
- Education with licensed nurses was completed on the five rights of medication administration.
- The medication error was reviewed with the medical director at an ad hoc QAPI meeting.
- The Director of Nursing will conduct audits of liquid morphine medication administration weekly until 100% compliance is achieved for 3 consecutive weeks, then monthly until 100% compliance is achieved for 3 consecutive months; all audits will be reviewed by the QAPI Committee.
Failure to Timely Report Allegations of Abuse to State Agency
Penalty
Summary
The facility failed to timely report allegations of abuse to the state agency for two residents. For one resident, a CNA documented in a written statement on 10/26/25 that on the previous night at approximately 11:15 PM, the resident reported that a CNA had torn her clothes and was rough with her. The CNA confirmed in an interview that this allegation was reported to a nurse on 10/25/25. However, the facility did not submit the allegation of staff-to-resident abuse to the state agency until 11:08 AM on 10/26/25, which was more than two hours after the resident’s initial report to facility staff. The ADON later stated that leadership only became aware of the incident by reading notes and that no one had made leadership aware at the time of the allegation. For another resident, the clinical record showed that the resident reported on 10/25/25 at 7:15 PM that a CNA was rough while providing care. The facility did not report this allegation of abuse to the state agency until 11:09 AM on 10/27/25, which exceeded the required two-hour reporting timeframe. In interviews, both the DON and the NHA confirmed that allegations of abuse must be reported within two hours and acknowledged that the alleged abuse was not reported within that timeframe. The facility’s abuse policy, last updated on 1/9/26, specified that allegations of abuse must be reported to the appropriate state regulatory authority within two hours, and the survey findings were reviewed with facility leadership during the exit conference.
Improper Cold Holding of Chicken Salad Sandwiches
Penalty
Summary
Surveyors identified a deficiency related to improper cold holding of chicken salad sandwiches prepared and served by the facility’s dietary department. During a kitchen observation with the Dietary District Manager (DDM), a steam table pan containing approximately 20 chicken salad sandwiches was seen on the counter at the left end of the steam table, with sandwiches stacked on top of one another. At that time, the sandwiches were being used on the tray line for room trays. A review of the lunch meal temperature log showed the chicken salad sandwiches had previously been documented within a safe temperature range. However, when the DDM checked the temperature of the chicken salad on a sandwich at 12:15 PM, it measured 54°F, which did not meet the facility’s policy requirement for cold food holding at less than 41°F. The DDM then obtained another tray of chicken salad sandwiches from the refrigerator and checked their temperature, which measured 57°F, also above the required cold holding temperature. The chicken salad recipe consisted of diced cooked chicken, mayonnaise, and pepper. During an interview, the Administrator stated that all food should be served at the right temperature to avoid any residents getting sick. The facility’s written policy titled “Food: Preparation,” revised 02/2025, specified that all foods will be held at appropriate temperatures, including less than 41°F for cold food holding. The deficient practice had the potential to affect 112 of 114 residents who could have been served these sandwiches.
Failure to Report Resident-to-Resident Abuse Allegation to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving one resident to the state agency as required by its abuse, neglect, and exploitation policy. One cognitively intact resident, with a Brief Interview for Mental Status (BIMS) score of 13 out of 15 on a quarterly MDS dated 04/21/25, struck another resident on 06/30/25. Progress notes and risk management documentation for that date indicated that this resident struck another resident with an open hand while lying in bed. The other resident involved had severe cognitive impairment, with a BIMS score of 4 out of 15 on an annual MDS dated 04/21/25, and was standing next to the first resident’s bedside attempting to calm or comfort her when the strike occurred. Progress notes and risk management notes for the cognitively impaired resident documented that the resident was slapped on the cheek or hit in the face with the back of the hand while trying to comfort the other resident. During interviews, an LPN confirmed that the cognitively intact resident smacked the cognitively impaired resident on the face with her left hand while in bed. The DON and the Regional Corporate Consultant both confirmed that this incident was not reported to the state agency. The Administrator stated that he believed the incident was accidental. The facility’s abuse, neglect, and exploitation policy dated 09/12/24 stated that the facility will report all alleged violations and all substantiated incidents to the state agency and other required agencies, but this allegation was not reported as required.
Failure to Thoroughly Investigate Allegation of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of potential abuse involving one cognitively intact resident and one severely cognitively impaired resident. The cognitively intact resident had an admission history dating back several years and a recent BIMS score of 13/15, indicating intact cognition. A progress note documented that this resident struck another resident with an open hand. The other resident, who had severe cognitive impairment with a BIMS score of 4/15, was documented as standing next to the first resident’s bedside and attempting to calm the resident when the slap to the cheek occurred. Internal risk management notes described that the cognitively intact resident hit the cognitively impaired resident in the face with the back of the hand while the latter was trying to comfort the former, and that the incident was determined by the facility not to be state reportable. The cognitively impaired resident was assessed for injury, with none noted, and the DON was notified. During interview, the DON acknowledged there was no documentation of resident and staff interviews included in the investigation. This was inconsistent with the facility’s Abuse, Neglect, Exploitation policy, which required that all allegations and incidents be investigated with a focus on whether abuse or neglect occurred, the extent of any occurrence, clinical evaluation for signs of injury, causative factors, and interventions to prevent further injury.
Failure to Assess and Respond to Acute Respiratory Distress
Penalty
Summary
A deficiency occurred when a resident with a history of a right femur fracture experienced a significant change in condition, specifically acute shortness of breath, during the early morning hours. Despite the resident's complaints and observable respiratory distress, there was a lack of timely and thorough assessment by nursing staff. Vital signs and oxygen saturation were either not monitored or not documented, and there was no evidence that the medical provider was promptly consulted during the initial onset of symptoms. The resident's oxygen saturation dropped to critically low levels, and interventions such as oxygen therapy were inconsistently applied and not properly documented. Multiple staff interviews revealed that although the resident was placed on oxygen and her condition was recognized as serious, there was confusion and delay in escalating care. Staff could not recall exact times of interventions, and several admitted to not documenting vital signs or assessments. The resident's respiratory status continued to deteriorate, and only after a significant delay was emergency medical assistance requested. When EMS arrived, the resident's oxygen saturation remained low, and she was ultimately transferred to the hospital unresponsive, where she later expired. The facility's own documentation and staff statements indicated a failure to follow established protocols for monitoring, assessment, and timely notification of changes in resident condition. There was also a lack of adherence to training regarding oxygen therapy and emergency response. These failures led to an Immediate Jeopardy finding due to the inadequate response to the resident's acute respiratory distress and the absence of appropriate clinical interventions and documentation.
Removal Plan
- Licensed nursing staff were re-educated on recognition of respiratory distress, respiratory assessments, including vital signs and oxygen saturation, initiation and monitoring of oxygen therapy, and provider notification
- Residents were screened by licensed nursing staff for respiratory distress
- Residents identified with respiratory distress were assessed and interventions were implemented
Some of the Latest Corrective Actions taken by Facilities in Delaware
- Educated licensed nurses on the five rights of medication administration (J - F0760 - DE)
- Implemented ongoing Director of Nursing audits of liquid morphine medication administration weekly until 100% compliance was achieved for 3 consecutive weeks, then monthly until 100% compliance was achieved for 3 consecutive months, with results reviewed by the QAPI Committee (J - F0760 - DE)
- Reviewed the medication error with the medical director at an ad hoc QAPI meeting (J - F0760 - DE)
Significant Morphine Dosing Error Due to Misinterpretation of mg and mL
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when an incorrect dose of concentrated morphine sulfate oral solution was administered. The resident had dementia and a quarterly MDS showing moderately impaired cognition with a BIMS score of 10 and was receiving opioids for pain. The physician’s order in place directed that the resident receive 0.25 mL (5 mg) of morphine sulfate concentrate oral solution every three hours as needed for pain, and on a later date a new order was entered for MS Contin (morphine sulfate) 15 mg extended-release tablets by mouth twice daily for pain. On the morning of the incident, the assigned LPN administered 15 mL of the concentrated morphine sulfate solution instead of the ordered 0.25 mL dose. In a written statement, the LPN reported that the electronic system displayed an ordered dose of morphine 15 mg, while the bottle label stated 0.25 mL, and that after seeking clarification from a supervisor, she was told to follow the dose listed in the MAR. The LPN then incorrectly interpreted 15 mg as 15 mL and administered that amount. Another nurse later confirmed that she had previously worked with the resident, was familiar with the correct 0.25 mL PRN dose, and had left 17.25 mL of morphine sulfate concentrate in the bottle at the end of her prior shift, while the LPN reported having given 15 mL to the resident. The error was discovered during shift exchange when the outgoing nurse recognized the discrepancy between milligrams and milliliters. Nursing notes documented that the resident had received 15 mL of liquid morphine, and the medical director’s note confirmed that, given the concentration of 20 mg/mL, the resident received 300 mg instead of the prescribed 5 mg. The facility determined that the nurse failed to perform the rights of medication administration when she misinterpreted 15 mg as 15 mL, resulting in the resident receiving 59 times the ordered dose of morphine sulfate solution. The resident required administration of naloxone intramuscularly on two occasions to reverse the overdosage, and the situation was identified by surveyors as immediate jeopardy, past non-compliance.
Removal Plan
- Upon discovery of the medication error, R5 was immediately assessed and the physician was notified; a new order for Narcan (Naloxone) was obtained and administered; R5's responsible party and Hospice were notified; R5 was placed on alert charting to monitor vital signs and respiratory status.
- An audit was completed on residents with orders for liquid morphine and no other errors were identified.
- An audit of residents receiving controlled substances was completed to determine if any other residents had orders for the same medication in two different forms and no other residents were identified.
- The facility conducted a root cause analysis.
- Education with licensed nurses was completed on the five rights of medication administration.
- The medication error was reviewed with the medical director at an ad hoc QAPI meeting.
- The Director of Nursing will conduct audits of liquid morphine medication administration weekly until 100% compliance is achieved for 3 consecutive weeks, then monthly until 100% compliance is achieved for 3 consecutive months; all audits will be reviewed by the QAPI Committee.
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