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 resident with stroke-related dysphagia, GERD, aphasia, and documented impulsive eating was not given consistent supervision or documented swallow precautions despite repeated SLP notes calling for slow pace, small bites, alternating solids and liquids, and upright positioning. Staff interviews showed that some CNAs and nurses were unaware of the resident’s choking risk and specific instructions. The resident was left alone eating breakfast in bed, became unresponsive, and EMS found severe airway obstruction by food; the resident died from food bolus airway obstruction.
Failure to Report Injury of Unknown Origin: A resident had multiple skin tears, bruises, discolorations, and redness documented on admission and again on a later skin assessment, including bruising to the face, chest, extremities, abdomen, and feet. An LPN stated new skin areas should trigger documentation, risk management, treatment, and notification of management, but the ADON confirmed no internal risk management report was initiated, and the facility lacked evidence that the injury of unknown origin was reported to the State Agency.
Failure to develop a person-centered care plan addressed a resident with stroke, GERD, and dysphagia who had documented aspiration risk and swallowing precautions from SLP. The resident reported trouble tolerating meds, pills getting stuck, and better tolerance when upright in a WC with water, but staff said they were unaware of the swallow precautions and the CNA task did not include specific instructions to monitor unsafe eating behaviors or use the identified strategies.
Admission Assessment Completed by LPN Without RN Oversight: An LPN completed a resident’s admission assessment and documented multiple skin findings, including skin tears, redness, and discolorations on several body areas. An RN stated that the full admission assessment, including skin, pain, fall risk, Braden, and oral assessments, is the responsibility of the nurse assigned to the resident’s room and that an LPN cannot complete the admission assessment without RN oversight.
Failure to protect residents from abuse. A resident with severe cognitive impairment physically assaulted a roommate while the roommate was asleep, and staff observed the attack. Another resident with severe cognitive impairment sexually grabbed a female resident, while the care plan had not been updated for years despite prior sexually inappropriate behavior. A third resident with intact cognition reported verbal mistreatment and being forcefully grabbed by a CNA at the nurse’s station.
Failure to report resident abuse, sexual misconduct, and injuries of unknown origin: Staff documented multiple resident-to-resident physical abuse incidents involving a resident with dementia and repeated sexual inappropriate behaviors by another resident, but the incidents were not reported to the Administrator or reflected on the reportable log. Staff interviews showed some events were observed but not escalated. The facility also documented bruises and other injuries of unknown origin for a severely cognitively impaired resident, but the Administrator confirmed the injuries were not reported to the SSA.
Failure to Supervise Resident With Dysphagia During Meals
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals for a resident with dysphagia, stroke, GERD, and aphasia. The resident’s record showed swallowing impairment identified by speech therapy, including oral residue, wet vocal quality, aspiration risk, and the need for precautions such as slow rate of intake, small bites, alternating liquids and solids, and upright positioning during and after meals. Speech therapy notes repeatedly described the resident as a very impulsive eater who needed cues to slow down and reduce bolus size, and discharge summaries continued to emphasize staff follow-through with these swallowing strategies. Although the resident’s assessments and therapy notes documented ongoing swallowing concerns and the need for supervision and cueing, the facility lacked evidence of a follow-up swallowing re-evaluation, an individualized care plan addressing dysphagia and aspiration prevention, or documentation that staff monitored the resident’s swallowing strategies in CNA or nursing records. The resident’s eating status was coded as requiring setup or clean-up assistance on multiple MDS assessments, and later speech therapy documentation noted a normal swallow without a clinical bedside assessment. Staff interviews showed inconsistent awareness of the resident’s swallowing precautions, and several staff members stated they were not informed that the resident was high risk for choking or that specific swallow precautions needed to be followed. On the day of the event, a CNA delivered breakfast to the resident in bed, repositioned him upright, and left him alone eating a meal that included ham, eggs, cheese, and an English muffin. About 20 minutes later, the resident was found unresponsive and a code blue was initiated. EMS documented severe airway obstruction by food, with repeated removal of ham and egg pieces from the airway and difficulty ventilating and intubating because of the obstruction. The resident was pronounced deceased, and the death certificate listed obstruction of the airway by food bolus while eating as the immediate cause of death.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to recognize and report an injury of unknown origin for one resident who was reviewed for abuse and injury of unknown origin. The resident was admitted with multiple skin findings documented on the admission assessment, including a closed skin tear to the right elbow, redness to the coccyx and sacrum, a left forearm skin tear with dressing in place, multiple discolorations to the bilateral upper extremities and right chest, a right forearm closed skin tear with a scabbed area, small discolorations to the bilateral lower extremities, and an upper arm skin tear with transparent dressing in place. A weekly skin assessment later documented bruising to the face, upper chest, bilateral upper extremities, fading bruises to the bilateral lower extremities, abdomen, and bilateral tops of the feet, along with a skin tear to the left upper extremity, multiple scabs to the bilateral upper extremities, redness to the sacrum, and a scab to the left lower and upper lip. An LPN stated the expectation was to document new skin areas, initiate risk management, initiate treatment, and notify management when staff identified a new skin area. The ADON stated no internal risk management report was initiated for any skin areas for the resident, and based on record review and interviews it was unclear whether the abdominal bruising was present on admission or occurred between the admission and weekly skin assessment. The facility lacked evidence that the injury of unknown origin was reported to the State Agency.
Failure to Include Swallowing Precautions in Care Plan
Penalty
Summary
Failure to develop a person-centered care plan to address a resident’s identified eating behaviors was cited for one resident reviewed for dysphagia. The resident was admitted with diagnoses including stroke, GERD, and dysphagia. An initial speech evaluation documented that the resident was at risk for aspiration during oral intake and identified strategies for safe swallowing, including alternating liquids and solids, general swallow techniques and precautions, cyclic ingestion, rate and bolus size modification, and maintaining an upright posture during meals and for more than 30 minutes afterward. Subsequent speech therapy documentation noted the resident reported difficulty tolerating medications and occasional episodes of larger pills becoming stuck in the proximal esophagus, with improvement when taking multiple sips of water and when seated upright in a wheelchair. The resident was educated on aspiration and choking risk and on safe swallow strategies, including small sips and bites, slow rate, upright seating, alternating solids and liquids, and taking medication with puree. Despite these documented swallowing precautions and observed eating behaviors, staff interviews indicated they were not aware of the resident’s swallowing precaution instructions, and the CNA task did not include instructions to monitor for unsafe eating behaviors or specific swallow precautions.
Admission Assessment Completed by LPN Without RN Oversight
Penalty
Summary
The nursing facility failed to provide services that met professional standards of quality when an LPN completed the admission assessment for one resident. The report states that R5 was admitted to the facility on 5/1/26, and the admission assessment documented multiple skin findings, including a right elbow skin tear that was closed, coccyx redness, a left forearm skin tear with dressing in place and unable to assess, multiple discolorations to both upper extremities and the right chest, redness to the sacrum, a right forearm closed skin tear with a scabbed area, small discoloration to both lower extremities, and an upper arm skin tear with transparent dressing in place. During interview, the LPN stated he completed the admission assessment for R5 and that any skin areas noted on admission would have been documented in the assessment. He also stated he recalled multiple areas on both arms and both legs, did not recall bruises on the abdomen, and said he would have a CNA complete the skin assessment so all areas would be identified. An RN stated that the nurse assigned to the resident's room is responsible for completing the fall risk, pain, skin, Braden, oral, and full admission assessment when the resident is admitted, and that an LPN cannot complete an admission assessment without RN oversight. Another RN confirmed she was working when R5 was admitted and was responsible for entering new physician orders, but did not complete any assessments when R5 was admitted.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from physical, sexual, and verbal abuse involving three residents. One resident with unspecified dementia and depression, who had a BIMS score of 0 out of 15, was involved in a physical altercation with a roommate. Nursing documentation stated the resident was witnessed hitting the roommate while the roommate was lying in bed, and staff later found the resident standing over the roommate and hitting her. The roommate, who had a BIMS score of 15 out of 15, was struck while sleeping and had a small scratch on the top of the left hand. Interviews with nursing staff confirmed the incident and that the residents were separated after staff intervened. A second resident with unspecified dementia and major depressive disorder, who had a BIMS score of 6 out of 15, was involved in a sexual abuse incident with another resident. Staff interviews stated that this resident touched, grabbed, and violated women, and that there was an incident in which he grabbed another resident’s breasts. The care plan for this resident addressed making sexual comments or touching others, but the record showed it had not been updated with new interventions since 2017. The DON stated she was unaware of the resident sexually fondling the other resident, and the Administrator also stated she was unaware of current issues involving this resident. A third resident with anxiety and depression, who had a BIMS score of 15 out of 15, reported verbal and physical mistreatment by a CNA. The resident stated the CNA was rude, threw back his covers, and later came behind him at the nurse’s station, grabbed his wheelchair, and pulled him back so hard that he had to hold onto the desk. A written statement from an LPN described an escalated verbal exchange and noted the resident resisted being moved. The facility’s follow-up documentation stated a verbal exchange was witnessed by nursing staff and that the CNA was terminated after the incident.
Failure to Report Resident Abuse, Sexual Misconduct, and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report resident-to-resident physical and sexual abuse incidents to the Administrator within two hours for three sampled residents and failed to report injuries of unknown origin to the State Survey Agency for one sampled resident. The report states that incidents involving residents R153, R82, R136, and R55 were documented in nursing notes, but none of those incidents were found on the facility reportable log. The Administrator later confirmed that none of the resident-to-resident incidents of physical and sexual abuse had been reported. R153, who had diagnoses including unspecified dementia and depression and a quarterly MDS BIMS score of 0 out of 15, was involved in multiple altercations with roommates. One note described R153 hitting roommate R82 while the roommate was lying in bed, with staff intervening and room changes implemented. Another note described R136 reporting that R153 hit her on the arm after R136 tried to pull a privacy curtain. A third note described R153 hitting roommate R55 in the chest after R55 moved a phone cord, followed by R153 throwing items across the room. Staff interviews showed that incidents were observed and discussed, but reporting to management was inconsistent or not completed. The report also identified sexual inappropriate behavior by R48, who had diagnoses including unspecified dementia and major depressive disorder and a BIMS score of 6 out of 15, toward another resident, R140, who had severe cognitive impairment with a BIMS score of 4 out of 15. R48's MAR documented six incidents of sexual inappropriate behavior toward others between August 2025 and May 2026, but there was no documentation identifying which residents were affected. An LPN described observing R48 touching a female resident's breasts and separately grabbing R140's breasts, but stated she did not report the incident and assumed others had done so. The SSD, DON, and Administrator stated they were unaware of these incidents, and the Administrator confirmed they had not been reported. The facility also failed to report injuries of unknown origin for R34, who had dementia with behavioral disturbance, type 2 diabetes, repeated falls, and severe cognitive impairment with a BIMS score of 0 out of 15. R34 was found with a bruise of unknown origin to the right shin, and earlier had bruises of unknown origin to the right breast and left upper arm, along with a contusion to the left great toenail. Documentation stated R34 could not explain the bruises, and staff statements described the injuries as unknown origin. The Administrator stated the facility found no documented evidence that R34's injuries of unknown origin had been reported to the SSA.
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Compliance trends in Delaware
Data through Apr 2026Comparisons below measure the most recent period May 2025 – Apr 2026 against the prior period May 2024 – Apr 2025 (two equal 12-month windows). The most recent 1 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 1-month reporting lag.
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: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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 May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025; the most recent 1 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 1 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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