Complete Care At Brackenville LLC
100 St. Claire Drive, Hockessin, DE 19707 · For profit - Limited Liability company · 104 certified beds · (302) 234-5420 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0565)
- it has 1 actual-harm citation
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $16,801 in federal fines (most recent 2024-02-02)
- its facility-reported quality-measure score sits well above its independent inspection score
- about 19% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 6.0% | 12.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 11.6% | 5.4% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.3% | 2.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 12.4% | 10.3% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 8.1% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 14.5% | 13.6% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 36.4% | 21.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 97.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.3% | 3.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 21.8% | 20.2% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.1% | 10.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.0% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 95.6% | 83.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 19.5% | 23.3% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 10.1% | 11.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.00 | 1.81 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.07 | 1.40 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
65.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 289 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 71.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 80 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.28 therapist hours per resident per day in 2026Q1 — more than 44% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 65.8%CMS range 58.8–72.5 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.5%CMS range 7.0–12.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 71.2% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 65.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 63.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.2% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.8%CMS range 4.3–9.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.22 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 104 beds and averages 99.1 residents a day — about 95% occupied, or roughly 5 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.85 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.69 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.53 hrs/resident/day on weekends vs 3.98 on weekdays — 11% thinner on weekends. RN hours go from 0.84 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · G2024-02-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility policy, the facility failed to ensure that supervision to prevent accidents for one Resident (R) 297 out of four sampled residents reviewed for accidents. This failure caused actual harm, when R297 sustained a subdural hematoma after a fall when Certified Nursing Assistant (CNA)1 left the resident sitting on the bedside, unattended, while gathering supplies for the resident's personal care. Findings include: Review of a policy provided by the facility titled Fall Prevention Program, dated 09/05/23 indicated .Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.The facility utilizes a standardized risk assessment for determining a resident's fall risk. The risk assessment categories (sic) residents according to low, moderate, or high risk .Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-03-05 · tag F0610 — failed to investigate and act on abuse reports — patternRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to thoroughly investigate allegations of abuse for four residents (Resident (R) 59, R88, R97, and R106) out of nine residents reviewed for abuse in a total sample of 40. This failure placed residents at risk of further abuse and a diminished quality of life.Findings include:1. Review of the admission Record, located in the Profile tab of the electronic medical record (EMR), revealed that R59 was admitted to the facility on [DATE] with diagnoses that included hemiplegia/hemiparesis (paralysis on one side of the body) following a cerebral infarct (stroke) and major depressive disorder.Review of the quarterly Minimum Data Set (MDS), located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 02/14/26, revealed R59 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R59 was cognitive intact.Review of the facility's investigation related to a 08/16/25 report of verbal abuse revealed R59 had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-03-05 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, record review, review of facility policies, and review of the manufacturer's manual, the facility failed to ensure pressure relieving air mattresses were correctly set according to the manufacturer's guidelines and residents' weights for three of five residents (Residents (R) 5, R48, and R85) reviewed for pressure ulcers out of a total sample of 40 residents. This failure placed residents at risk for skin breakdown, delayed wound healing, pain, infection, and potentially avoidable complications.1. Review of R5's Face Sheet, located in the electronic medical records (EMR) under the Profile tab, revealed an admission date of 10/17/25 with the following diagnoses: myocardial infarction (heart attack) type 2, atypical atrial flutter (heart arrythmia), unspecified dementia, and reflux disease.Review of R5's revised 01/15/26 Care Plan, located in the EMR under the Care Plan tab, revealed [R5] has a pressure ulcer to her sacrum and left buttock. Interventions included following the manufacturer's recommendation for proper function of the air mattress.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-05 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and facility policy review, the facility failed to ensure accommodation of needs for two of two residents (Resident (R) 71 and R5) in the sample of 40. Specifically, the facility failed to address necessary wheelchair repairs for R71 and did not provide R5 with access to a functioning call light. This created a potential risk for resident injury. Findings include: 1. Review of R71's electronic medical record (EMR) titled Face Sheet, located under the Profile tab, indicated an admission date of 10/25/24 with diagnoses of traumatic brain injury and quadriplegia. Review of R71's EMR titled Care Plan, located under the Care Plan tab, dated 10/28/24, indicated that R71 was at risk for skin integrity due to fragile skin. Review of R71's EMR quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/14/25 indicated the staff were unable to determine a Brief Interview for Mental Status (BIMS) score. R71 was dependent on all activities of daily living from staff. During an observation on 03/02/26 at 11:52 AM, R71 was seated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-05 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and resident interviews, and policy review, the facility failed to ensure hearing services were provided for one of one resident (Resident (R) 97 reviewed for vision and hearing services. The facility's failure to ensure the provision of timely hearing services had the potential to negatively impact R97's ability to effectively communicate. A total of 40 residents were reviewed in the sample. Findings include: Review of R97's admission Record, dated 03/05/26 and found in the electronic medical record (EMR) under the Profile tab, revealed R97 was admitted to the facility on [DATE]. The resident's diagnoses included type 2 diabetes and epilepsy.Review of R97's Audiology Consultation Report, dated 09/04/25 and found in the EMR under the Miscellaneous tab, revealed the resident had hearing loss and indicated the resident was in need of, and agreed to, a hearing aid evaluation for an assistive hearing device.Review of R97's quarterly Minimum Data Set (MDS) with an Assessment Reference…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff interviews, and facility procedure review, the facility failed to ensure the routine provision of ordered respiratory services for one resident (Resident (R) 89) of two residents reviewed for respiratory services. The facility's failure created the potential for R89 to develop complications related to the ineffective administration of oxygen. A total of 40 residents were reviewed in the sample. Findings include:Review of R89's admission Record, dated 03/05/26 and found in the electronic medical record (EMR) under the Profile tab, revealed R97 was admitted to the facility on [DATE]. The resident's diagnoses included chronic obstructive pulmonary disease (COPD) and pulmonary mycobacterial infection.Review of R89's physicians orders, found in the EMR under the Orders tab, revealed orders, with an original order date of 02/04/26, for the resident to receive oxygen three liters continuously per nasal cannula and for the resident's humidification bottle and oxygen tubing to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-05 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observations, interviews, and review of the facility policies, the facility failed to ensure staff followed enhanced barrier precautions (EBP) and standard nursing precautions while providing care for one of one resident reviewed on EBP (Resident (R) 5). Specifically, a Certified Nurse Aide (CNA) failed to follow personal protective equipment (PPE) guidelines and wear a gown and gloves while performing incontinent care. This failure had the potential to cause further infection to the resident's wounds. Findings include:Review of R5's Face Sheet, located in the electronic medical records (EMR) under the Profile tab, revealed an admission date of 10/17/25, with the following diagnoses: myocardial infarction (heart attack) type 2, atypical atrial flutter (heart arrythmia), unspecified dementia, and reflux disease.Review of R5's Care Plan, revised 01/13/26 and located in the EMR under the Care Plan tab, revealed, [R5] requires enhanced barrier precautions related to (wound, indwelling medical device, infection or colonization with MDRO) It did not specify the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-15 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, it was determined that for one (R2) out of three residents sampled for care plans, the facility failed to develop a person-centered care plan for the refusal of medications. Findings include:6/27/25 - R2 was admitted to the facility with diagnoses including but not limited to muscle weakness, bladder cancer and ocular myasthenia gravis. R2's admission medications included pyridostigmine bromide oral tablet 60 mg two times a day for the treatment of ocular myasthenia gravis.7/1/25 - R2's clinical records documented a BIMS score of 15, indicating a completely cognitive intact status.6/28/25 - 7/22/25 - R2's clinical records documented twenty-eight (28) episodes of refusal of pyridostigmine bromide tablets out of forty-nine (49) opportunities.9/12/25 11:30 AM - A review of R2's clinical records lacked evidence of a care plan for the refusal of medications.9/12/25 1:00 PM - During an interview, finding was confirmed with E2 (DON).9/15/25 3:15 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E3 (RN).
- Potential for harm · D2025-09-15 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, it was determined that for one (R5) out of three residents sampled for acceptable standards of clinical practice, the facility failed to ensure that R5's medication was administered according to the physician's order. Findings include:An undated facility document entitled, Rights of Medication Administration, included:Right PersonRight MedicationRight DoseRight TimeRight RouteRight ReasonRight Documentation. 7/14/25 - R5 was admitted to the facility with diagnoses including but not limited to infection of the right lower leg, right heel pressure ulcer, and resistance to multiple antibiotics.7/14/25 6:34 PM - R5's medications included, Daptomycin-sodium chloride intravenous solution, give 800 mg intravenously daily.7/15/25 - R5's clinical record documented a BIMS score of 15, indicating a cognitively intact status.7/21/25 11:00 AM - R5's clinical record documented, .Resident was ordered Daptomycin 800mg IV 1xday, Nurses were administering Daptomycin 850mg IV daily with wrong patient identifiers on IV bag as sent by pharmacy despite not matching…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-15 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, it was determined that for one (R5) out of three residents sampled for medication administration, the facility failed to ensure that R5's medication was administered per the physician's order. Findings include:Based on record review and interview, it was determined that for one (R5) out of three residents sampled for medication administration, the facility failed to ensure that R5's medication was administered per the physician's order. Findings include:3/13/23 - A facility documented entitled, Medication Administration, and updated 6/3/24, documented, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice.7/14/2025 - R5 was admitted to the facility with diagnoses including but not limited to infection of the right lower leg, right heel pressure ulcer, and resistance to multiple antibiotics.7/14/25 6:34 PM - R5's medications included, Daptomycin-sodium chloride intravenous solution, give 800 mg…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-02-14 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to act promptly on the grievances and recommendations of the resident council group for seven of 12 months of resident council minutes reviewed and to the extent practicable, the facility staff failed to revise or develop new policies related to resident rights, life, and care. These failures resulted in resident concerns going unaddressed. Findings include: During a group meeting on 02/12/25 at 3:51 PM with five residents (R), R298, R12, R65, R18, and R57, each resident attending the group meeting was listed on previous month's resident council meeting notes list of attendees. The group of residents indicated they reported the same concerns at every monthly meeting but did not receive an explanation or resolution to their concerns and continued complaints. The group also reported in agreement that the administrator took over in the monthly resident council meeting and was rude to the residents during the meeting. Resident council meeting notes dated March 2024 documented that a resident complained that the towels smell bad…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 19 citations
- Potential for harm · Dcited before2025-02-14 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interviews, and facility policy review, the facility failed to determine if one of one resident (Resident (R) 66) was assessed as clinically appropriate to self-administer medications of 38 sample residents. The failure of the facility to leave medications at the bedside unattended prior to an assessment, created an unsafe environment for the residents and other residents in the area. Findings include: Review of the facility's undated policy titled, Resident Self Administration of Medications revealed It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely .11. The care plan must reflect resident self-administration and storage arrangements for such medications. Review of R66's electronic medical record (EMR) undated admission Record located under the Profile tab, indicated the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-14 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, document review, and facility policy review, the facility failed to ensure the accurate code status was documented and available for reference for two of 36 sampled residents, (Resident (R)49 and R38). This deficient practice could result in not following the specific residents' wishes documented in the advanced directive. Findings include: Review of R49's Admission record located in the electronic medical record (EMR) under the Profile tab revealed an admission date of [DATE]. The Brief Interview for Mental Status (BIMS) assessment, dated [DATE] and located under the Documents tab, revealed R49 scored nine of 15, indicating R49 was moderately cognitively impaired. The documented code status, Full Code, was found in EMR, Resident Profile tab, Face Sheet but no documentation was identified to support the resident's decision. Review of R38s Admission record located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of [DATE]. The BIMS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-14 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received alternative measures prior to installation of side rails for one of one resident reviewed for side rails (Resident (R) 9) of 38 sampled residents. The lack of alternate side rail measures could lead to potential safety concerns related to bed rail use for residents with bed rails. Findings include: Review of R9's Face Sheet, located in the electronic medical record (EMR) under the Profile tab revealed the resident was re-admitted to the facility on [DATE] with diagnoses which included legal blindness and gout. Review of R9's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/14/25 and located in the resident's EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of seven out of 15, which indicated the resident's cognition was severely impaired. Review of R9's Care Plan, dated 06/05/23 and located in the resident's EMR under the Care Plan tab, revealed The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-14 · tag F0725 — failed to have enough nursing staff — isolatedProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure call lights were answered timely for one of 38 sample residents (Resident (R) 44) reviewed for staffing. This failure had the potential to put the residents at risk. Findings include: Review of R44's admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 03/03/23. Review of R44's admission Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 11/20/24, revealed R44 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. She was dependent on staff for toileting, bathing, and dressing. During a continuous observation on 02/13/25 from 9:16 AM until 9:54 AM, R44's call light remained on. During this time, Licensed Practical Nurse (LPN) 1 stood by the medication cart from 9:16 AM to approximately 9:35 AM, which was parked by R44's room.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-02-02 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to have sufficient staff on a 24-hour basis to care for residents' needs, as identified through the facility assessment staff-to-resident ratios and the Payroll Based Journal (PBJ) Staffing Data Report supplied from the Centers for Medicare and Medicaid Services (CMS), resident council minutes, and views from the resident group. Additionally, the facility failed to respond in a timely manner to the needs of six residents (R)1, R44, R59, R33, R50, and R89 reviewed out of a total sample of 22. Findings include: Review of the Payroll Based Journal (PBJ) Staffing Data Report for fiscal year quarter four for 2023 [July 2023 through September 2023] and supplied by CMS revealed the facility triggered for excessively low weekend staffing as determined by information submitted by the facility. Review of the Facility Assessment Tool reviewed 07/24/23 and supplied by the facility, revealed the nurse to resident ratios for different shifts to be 1:15 [nurse to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-02 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and policy review, the facility failed to ensure the food was palatable for four of 22 sampled residents (Resident (R)1, R59, R33, and R65) and residents attending Food Committee meetings. The food was not at a palatable temperature when residents received their meals; condiments were not consistently provided, and food was not flavorful/prepared properly. Findings include: Review of the Food: Quality and Palatability policy dated February 2023 revealed, Food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. 1. Resident interviews with R1, R59, R33, and R65 revealed concerns with food palatability: a. During an observation and interview on 01/30/24 at 11:27 AM, R1 was observed with her breakfast tray (scrambled eggs, toast, orange juice) remaining on the overbed table in front of her untouched. R1 stated the eggs were cold when she received them, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-02 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review and policy review, the facility failed to ensure there was not more than a 14-hour time span between dinner and breakfast the next day. This failure affected approximately 19 residents out of 99 total residents, who ate in the west dining room. The extended time between dinner and breakfast had not been approved by the resident group. Findings include: Review of the Frequency of Meals policy dated October 2022 revealed, The time between a substantial evening meal and breakfast the following day will not exceed 14 hours, except when a nourishing snack is served at bedtime. Up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span and a nourishing snack is provided. 1. Review of the undated [Name of facility] Meal Service Times provided by the facility and posted on the wall near the dining room revealed a 14-and-a-half-hour gap between dinner and breakfast for residents eating the dining rooms: Breakfast Cart service for hallways begins at 8:00 am Dining room…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-02 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, policy review, and review of the US (United States) Food Code, the facility failed to ensure the kitchen was maintained in a sanitary condition to prevent the potential spread of foodborne illness to 97 out of 99 residents. Specifically, the facility failed to maintain a sanitary kitchen; label, date, and store food properly; use the handwashing sink for handwashing only and ensure a garbage can was in place; ensure equipment was clean; ensure staff followed hand hygiene/glove use standards; and ensure staff had their hair covered. The facility failed to ensure proper infection control practices were maintained for a sugar and a flour container which held scoops previously used by the kitchen staff. The facility failed to ensure Dietary Aide (DA)1 removed his personal disposable cup from a reach in refrigerator which could potentially contaminate food items which were then served to residents. Findings include: US Food Code 2022-- Indicated .Explaining correct procedures for cleaning and sanitizing utensils and food-contact surfaces of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-02 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and facility policy review, the facility failed to ensure elopement risks and wander guard assessments were updated to promote dignity for one Resident (R) 301 of two reviewed for elopement risk and wander guard use. The facility failed to ensure Certified Nursing Assistant (CNA)3 closed the privacy curtain while providing personal care to R39. R39's breasts and brief were exposed to public view. Additionally, R89 was not provided an opportunity for dignity when she sat in her wheelchair, while wearing a brief for over an hour. Findings include: 1. Review of a policy provided by the facility titled Resident Alarms dated 03/14/23 indicated, .It is the policy of this facility to utilize residents' alarms in limited circumstances, in accordance with the resident's needs, goals, and preferences, so that the resident will be able to attain or maintain his or her highest practicable level of physical, mental, and psychosocial well-being.Wander/elopement alarms-includes…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-02 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, record review, and facility policy review, the facility failed to assess one of one sampled resident (Resident (R) 65) for self-administration of medications. This failure led to medications being left at the bedside where they could be accessed by other residents. Findings include: Review of a policy provided by the facility titled Resident Self-Administration of Medications dated 2022 indicated .It is the policy of this facility to support each resident's rights to self-administrator medications after the facility's interdisciplinary team has determined which medication's may be self-administered safely.When determining if self-administration of medication will be documented is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following.The medications appropriate and safe for self-administration.The resident's ability to ensure that medication is stored safely and securely.The care plan must reflect resident self-administration…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-02 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to ensure residents were protected from verbal abuse by staff for one resident (R)59 of seven residents reviewed for abuse in a total sample of 22 residents. Findings include: Review of the Abuse, Neglect & Misappropriation policy dated May 2021 revealed, Each resident has the right to be free from abuse . Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Verbal abuse means the use of oral, written, gestured language that willfully includes disparaging and derogatory terms to residents . Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R59 was admitted to the facility on [DATE] with diagnoses which included anxiety disorder, mild dementia, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/23 in the EMR…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-02 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility policy, the facility failed to ensure that an allegation of neglect was reported to the State Survey Agency (SSA) in a timely manner for one resident (Resident (R) 297) reviewed for abuse/neglect in a total sample of seven residents. This failure had the potential for other allegations of abuse/neglect to not be reported in a timely manner. (Cross Reference F689) Findings include: Review of a policy provided by the facility titled Abuse, Neglect & Misappropriation, dated 05/21 indicated .Response and Reporting of Abuse, Neglect and Exploitation - Anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect or exploitation is suspected, the Licensed Nurse should.Contact the State Agency.Each covered, individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-02 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility policy, the facility failed to ensure that a thorough investigation of an allegation of staff-to-resident verbal abuse for one resident (R)346 of seven residents reviewed for abuse in a total sample of 22 residents. Findings include: Review of a policy provided by the facility titled Abuse, Neglect & Misappropriation, dated 05/21 indicated .Investigation of Alleged Abuse, Neglect and Exploitation. When suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Components of an investigation may include.Interview the involved resident, if possible, and document all responses. If resident is cognitively impaired, interview the resident several times to compare responses.Interview all witnesses separately. Included roommates, residents in adjoining rooms, staff members…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-02 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure two (Resident (R) 70 and R26) out of 40 sampled residents had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly could potentially lead to inaccurate assessment and care planning of the resident. Findings include: Review of the RAI Manual, dated 10/01/19, indicated, . It is important to note here that information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT (Interdisciplinary Team) completing the assessment. 1. Review of R70's electronic medical records (EMR) titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of amyotrophic lateral sclerosis (ALS) disease. Review of R70's EMR titled…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-02 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, clinical record review, and facility policy review, the facility failed to ensure that a biopsied specimen for one Resident (R) 298 of one residents reviewed for surgical procedure in a total sample of 22 residents was handled properly after a surgical procedure and not destroyed prior to analysis by pathology. Findings include: Review of the facility policy, provided by the facility, titled Biohazard Labeling dated 01/19 indicated .Any container used to store, transport, or ship blood or other potentially infectious materials must be properly labeled with a biohazard warning before it is transported within, or removed from, the premises. Review of R298's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE], with diagnoses of muscle weakness and morbid obesity. Review of R298's EMR titled admission Minimum Data Set [MDS] with an Assessment Reference Date (ARD) of 02/16/23 indicated the resident had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-02 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews, the facility failed to provide respiratory care per standards of practice for two of two sampled residents (Resident (R) 91 and R16). Specifically, the facility failed to ensure respiratory equipment was stored properly for R91 and R16. The failure to store respiratory equipment consistent with professional standards had the potential to cause contamination and damage to the respiratory equipment. Findings include: Review of a undated policy provided by the facility titled CPAP [Continuous Positive Airway Pressure], CPAP-AUIO [continuous positive Airway pressure with Auto-titration], BiPAP [Bilevel Positive Airway Pressure], AUIO-PAP [Auto-titration Bilevel positive Airway pressure], & [and] BiPAP ST [Bilevel Positive Airway pressure with spontaneous/timed rate] indicated . When not in use, store clean machine in drawstring back in the respiratory closet. The policies did not address the storage of a nebulizer machine face mask between use. 1. Review of R91's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-02 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observations, interviews, and review of the facility assessment, the facility failed to ensure one Certified Nursing Assistant (CNA)3 was competently trained to provide one Resident (R)39 personal care in a dignified manner (Cross Reference F550). Additionally, the facility failed to ensure one Licensed Practical Nurse (LPN) 5 was competent to handle a biopsied specimen and not to destroy it prior to analysis by a pathologist (Cross Reference F684). Findings include: Review of a document provided by the facility titled Facility Assessment Tool, dated 06/06/23 indicated . [Name of the facility] has an extensive library of clinical policies and procedures that are developed through a Governing body, Regional Clinical Staff and at the center level. Policies and procedures are based on federal and state regulations, standards from professional organizations and professional clinical resources, an annual review is performed by the Practice Councils and the center Quality improvement Committee to determine if updates are needed. However, policies and procedures are…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-02 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and facility policy review, the facility failed to ensure one of two medication rooms was secured by closing and locking the door to the room. This failure had the potential of permitting unauthorized individuals access to the medication storage room. Findings include: Review of the facility policy titled, Medication Storage revised on 03/13/23 indicated, It is the policy of this facility to ensure that all medications housed on our premises will be stored in the. medication rooms according to the manufacturer's recommendations . and security.All drugs and biologicals will be stored in locked . medication rooms. Observation on 02/01/24 at 5:47 AM revealed the door to the medication storage room propped open by a plastic milk crate. Registered Nurse (RN)2 was then observed to push the crate out of the way and allow the door to close. During an interview at 5:47 AM on 02/01/24 RN2 confirmed the medication room door had been propped open and stated, So I shut it. She stated it should not be propped open. During an interview with the Director of Nursing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-02 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interviews, and policy review for four of 11 (Residents (R) 22, 91, 400, and 401) reviewed for medication administration, the facility failed to ensure the Evencare G3 glucometer used for diabetic monitoring was cleaned and disinfected per the manufacturer's instructions, failed to ensure hand hygiene was performed by one staff per facility policy, failed to store trash and personal belongings per infection control practices, and failed to wear Personal Protective Equipment (PPE) per facility policy for three staff. This failure puts residents and staff at potential risk of developing infections. Findings include: Review of the Evencare G3 glucometer manufacturer guidelines revised on 02/18 indicated .The EVENCARE G3 Meter should be cleaned and disinfected between each patient .To disinfect your meter, clean the meter surface with one of the approved disinfecting wipes .Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$16,801 in federal fines across 1 penalty.
- $16,801 — penalty dated 2024-02-02
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to COMPLETE CARE — 85 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.1 | +0.9 vs chain |
| Health inspection | 3 of 5 | 2.7 | +0.3 vs chain |
| Staffing | 3 of 5 | 2.3 | +0.7 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 84 homes this chain runs (chain average 3.1★, per CMS)
Showing 40 of 84; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PC DE OPCOS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 06/01/2021 |
| PC WTA OPCO HOLDCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/01/2021 |
| SMS 2021 TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 06/01/2021 |
| STEIN, SHALOM | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; TRUSTEE OF THE SNF | — | since 06/01/2021 |
| WELLTOWER INC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | — | since 06/01/2021 |
| COX, VICKIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2021 |
| DIFILIPO, REBECCA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/30/2022 |
| INGLIS, RONALD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2021 |
| MANSFIELD, MELISSA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2021 |
| RASTOGI, RITU | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2021 |
| SILVERBERG, NISANEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2021 |
| AURORA GUARDIAN HOLDCO II CO-BORROWER, LLC | Organization | ADP OF THE SNF | — | since 06/01/2021 |
| AURORA GUARDIAN HOLDCO II MEZZ BORROWER, LLC | Organization | ADP OF THE SNF | — | since 06/01/2021 |
| AURORA GUARDIAN HOLDCO II, LLC | Organization | ADP OF THE SNF | — | since 06/01/2021 |
| AURORA GUARDIAN II REALTY, LLC | Organization | ADP OF THE SNF | — | since 06/01/2021 |
| AURORA GUARDIAN PARTNERS II LLC | Organization | ADP OF THE SNF | — | since 06/01/2021 |
| BRACKENVILLE CENTER REALTY | Organization | ADP OF THE SNF | — | since 06/01/2021 |
| J & R FAMILY INVESTMENTS, LLC | Organization | ADP OF THE SNF | — | since 06/01/2021 |
| L FRIEDMAN 2018 FAMILY TRUST | Organization | ADP OF THE SNF | — | since 06/01/2021 |
| L FRIEDMAN FAMILY HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 06/01/2021 |
| LANDAU FAMILY INVESTMENT TRUST | Organization | ADP OF THE SNF | — | since 06/01/2021 |
| M FRIEDMAN 2018 FAMILY TRUST | Organization | ADP OF THE SNF | — | since 06/01/2021 |
| PC WTA ACQUISITION LLC | Organization | ADP OF THE SNF | — | since 06/01/2021 |
| PC WTA MULTI-STATE LLC | Organization | ADP OF THE SNF | — | since 06/01/2021 |
| PEACE CAPITAL HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 06/01/2021 |
| R&J FAMILY INVESTMENTS LLC | Organization | ADP OF THE SNF | — | since 06/01/2021 |
CMS files one row per role, so the 37 rows in the source record cover these 26 parties — each is shown once here with every role it holds. Nothing is omitted.
19 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2.7M paid to related parties — landlords or management companies under common ownership — equal to about 19% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in DE
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Delaware Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 085042. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.