Delaware Veterans Home
100 Delaware Veterans Blvd, Milford, DE 19963 · Government - State · 144 certified beds · (302) 424-6000 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (5/5)
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2026
- it has 2 actual-harm citations
- a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $118,757 in federal fines (most recent 2026-03-12)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 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, and staffing on its payroll (PBJ) submissions — 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 |
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 held steady at 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 | 14.8% | 12.7% | 15.4% | typical |
| Long-stay residents who lose too much weight | 4.3% | 5.4% | 5.4% | better |
| 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 | 1.1% | 2.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 10.3% | 6.5% | check this* — see note marked star below the table |
| 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 | 1.8% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 23.2% | 13.6% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 22.9% | 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 | 2.6% | 3.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 18.5% | 20.2% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.4% | 10.7% | 17.1% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.77 | 1.81 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.13 | 1.40 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
Therapy staffing: this home’s payroll records show 0.25 therapist hours per resident per day in 2026Q1 — more than 34% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims 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 | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 144 beds and averages 63.7 residents a day — about 44% occupied, or roughly 80 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 7.08 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 2.46 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.89 is at or above 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 6.28 hrs/resident/day on weekends vs 7.40 on weekdays — 15% thinner on weekends. RN hours go from 2.77 to 1.69 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% 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.
21 citations, most serious first. The 12 most serious are shown; the remaining 9 are one tap away and print in full.
- Actual harm · Gcited before2026-03-12 · 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 record reviews, interviews, and review of the facility's policy, the facility failed to ensure four of nine sampled residents (Resident (R) 4, R46, R8, and R41) reviewed for abuse were free from resident-to-resident physical abuse. On 07/22/25, R8 pushed R4 to the ground. As a result, R4 sustained a closed left radius fracture, a closed, displaced, comminuted right proximal humerus fracture, and a closed, displaced right distal clavicle fracture. Findings include:. 1.Review of the facility's 5-day Follow Up Report dated 07/25/25 provided by the Administrator, revealed that at the time of the incident on 07/22/25 at 5:30 PM, staff heard someone screaming. Upon entering the hallway, staff observed R4 sitting on the floor holding his head. Staff immediately ran down the hallway to investigate. The Nursing Supervisor/Registered Nurse (NS/RN) reviewed the surveillance video and noted R8 walking down the hall into R4's room. After a few seconds, R4 was seen coming out the room with R8 behind him. R8 pushed R4…
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.
- Actual harm · Gcited before2025-03-06 · 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
Based on record review and interview, it was determined that for four (R422, R9, R35 and R41) out of four residents reviewed for quality of care, the facility failed to ensure care/treatment in accordance with professional standards of practice. For R422 the facility failed to provide treatment for a urinary tract infection for four days causing a change in condition that required a transfer to the hospital. This delay in care resulted in harm to R422. For R9, the facility failed to provide treatment for a urinary tract infection for two days. For R35 and R41, the facility failed to follow a doctor's order. Findings include: Cross Refer F773 1. Review of R422's clinical record revealed: 5/23/24 - R422 was admitted to the facility with a history of a stroke affecting his right dominant side, Parkinson's disease and dementia. 6/13/24 - A nursing progress note documented that E16 (MD) was notified that R422 was getting confused, disoriented and drowsy. 6/13/24 - A physician's order was written by E16 for a urinalysis and urine culture. 6/14/24 - A nursing progress note documented 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 · F2026-03-12 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 and facility policy review, the facility failed to ensure kitchen staff thoroughly cleaned and air-dried pots and pans as well as insured one of two can openers had been cleaned. This failure increased the potential risk of foodborne illness and had the potential to affect 61 of 62 residents that received food through dietary services. One resident received nutrition through tube feeding.Findings include:During an observation on 03/09/26 at 10:30 AM, three 6x6x6 stainless steel pans and six 6x24x6 stainless steel pans were stacked together on storage rack were noted to be wet inside with some food debris remaining. During an interview on 03/09/26 at 10:50 AM, the Food Service Director (FSD) stated, The pans are wet and they shouldn't be. They should be dry before they get put away and the pans should be clean and have no food remining on them. During an observation on 03/09/26 at 11:00 AM, one of two can openers bolted to a preparation table had a black substance on the blade. During an interview at this time, the FSD stated The blade is dirty. It…
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 before2026-03-12 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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, interview, and facility policy review, the facility failed to ensure care plans were revised and updated for one (Resident (R)19) out of 23 resident care plans reviewed. R19 developed two additional wounds and had protective devices added and were not updated to his comprehensive care plan. This had the potential for the resident to have unmet care needs.Findings include: Review of R19's Face Sheet located in the electronic medical record (EMR) and under the Admissions tab revealed the resident was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease with late onset and dementia (severe) with behavioral disturbances.Review of R19's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/24/25 located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of zero out of 15 indicating severe cognitive impairment. Review of R19's Tasks located in the EMR under the Tasks List tab revealed certified 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 before2026-03-12 · 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 interview and record review, the facility failed to provide quality for one (Resident (R)47) of one resident reviewed for physician orders in the sample of 23 residents. Specifically, the facility failed to perform R47's daily weights as ordered. Failure to obtain daily weights as ordered for a resident with congestive heart failure can lead to potential worsening of the condition as well as hospitalization and decline in overall condition.Findings include:Review of R47's electronic medical record (EMR) Face Sheet under the admission tab indicated R47 was admitted to the facility on [DATE] with diagnoses including acute kidney failure, heart failure, atrial fibrillation, atherosclerotic heart disease, and edema. Review of R47's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/31/25 in the EMR under the MDS tab documented R47 had heart failure and renal insufficiency.Review of R47's EMR Order Summary Report dated 03/12/26 found under the Orders tab in R47's EMR documented an…
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 before2026-03-12 · 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 observations, record reviews, interviews, and document review, the facility failed to prevent an accidents. Specifically, a resident fell from a Hoyer lift during a transfer for one out of three residents (Resident (R)51) reviewed for Hoyer lifts. This failure to prevent an accident which resulted in R51 experiencing actual harm of a skin tear to the resident's right elbow.Findings include:Review of R51's electronic medical record (EMR) Face sheet under the Admissions tab that R51 was admitted on [DATE]. Under the EMR section titled Medical Diagnosis tab had pertinent diagnosis including spinal stenosis, lumbosacral region, Alzheimer's disease, vascular dementia with other behavioral disturbance, bipolar disorder, pain, spinal stenosis, Review of R51's quarterly Minimum Data Set (MDS) in the EMR under the MDS tab with an Assessment Referent Date (ARD) of 08/13/25 with a Brief Interview for Mental Status (BIMS) score could not be conducted due to resident was rarely/never understood. Review of the MDS…
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 · D2026-03-12 · 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, record review, and interview, the facility failed to assess the entrapment risk of bedrails used for mobility assistance and failed to obtain consents for three of eight residents (Resident (R)19, R24, and R37) reviewed for accident hazards out of a total sample of 23 residents. Additionally, R24's first bed rail assessment indicated the resident did not need bed rails; however, bed rails were on the bed. Failure to assess and determine hazards could lead to injury, entrapment, or death. Findings include:1. Review of R19's Face Sheet located in the electronic medical record (EMR) and under the Admissions tab revealed the resident was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease with late onset and dementia (severe) with behavioral disturbances.Review of R19's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/24/25 located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of zero out of 15…
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 · D2026-03-12 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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, interview, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to ensure two of five residents (Resident (R) 5 and R13) reviewed for pneumococcal vaccines out of a total sample of 23 residents were offered an updated pneumococcal vaccine. The facility further failed to ensure their pneumococcal policy was revised to reflect updated guidance per the CDC for the administration of pneumococcal vaccines. This had the potential for the residents to have an increased risk of contracting pneumonia. Findings include:1.Review of R5's Face Sheet located in the electronic medical record (EMR) under the Admissions tab revealed the resident was admitted to the facility on [DATE] and was over [AGE] years old.Review of R5's Immunization Record located in the EMR under the Immunizations tab revealed R5 received the pneumococcal polysaccharide vaccine (PPSV) 23 on 11/11/21. There was no evidence that the resident was offered the PCV15,…
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 before2025-03-06 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 five (R1, R11, R64 and R66) out of nineteen sampled residents, the facility failed to have input from all required interdisciplinary team (IDT) members at the residents' care plan meetings. Findings include: 1. 2/11/08 - R1 was admitted to the facility. 1/15/25 - A quarterly MDS was completed. 1/28/25 - A quarterly care plan meeting note lacked evidence of input from the physician. 10/16/24 - A quarterly MDS was completed. 10/29/24 - A quarterly care plan meeting note lacked evidence of input from the physician. 7/17/24 - An annual MDS was completed. 7/30/24 - An annual care plan meeting note lacked evidence of input from the physician. 2. 6/11/24 - R11 was admitted to the facility. 6/17/24 - An admission MDS was completed. 7/9/24 - A quarterly care plan meeting note lacked evidence of input from the physician. 9/11/24 - A quarterly MDS was completed. 9/24/24 - A quarterly care plan meeting note lacked evidence of input from the physician. 12/11/24 - A quarterly MDS was completed. 12/26/24 - A quarterly care plan…
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 · D2025-03-06 · tag F0626 — isolatedPermit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
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 interview, it was determined that for one (R47) out of two residents reviewed for hospitalization, the facility lacked evidence that R47 was allowed to return timely to the facility. 11/26/24 - R47 was admitted to the facility. 12/6/24 - R47 was admitted to the hospital for altered mental status and for a psychiatric evaluation. The admission history and physical also reflected that R47 had recently been diagnosed with a urinary tract infection. 12/8/24 - A hospital progress note revealed Barriers: Patient is medically cleared for discharge. VA home is not taking patient on weekends . 12/9/24 - A discharge summary revealed that His mental status has improved, he has been pleasantly confused during the hospital stay, which appears to be his baseline. He is medically stable for discharge. 12/10/24 - A daily medical progress report revealed Barriers to discharge: medically cleared. Discharge disposition: placement issues. 12/12/24 - A daily progress report revealed Disposition hospital…
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 before2025-03-06 · 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
Based on interviews and record review, it was determined that for one (R4) out of three residents reviewed for accidents, the facility failed to implement the correct assistant device to transfer the resident to prevent accidents. Based on review of the facility's evidence to correct the non-compliance and the facility's substantial compliance at the time of the current survey, the deficiency was determined to be past non-compliance as of 12/20/24. Findings include: Review of R4's clinical record revealed: 7/11/23 - R4 was admitted to the facility. 11/20/23 - A new diagnoses for R4 included, but was not limited to, peripheral autonomic neuropathy, lack of coordination, generalized muscle weakness and unsteadiness on the feet. 10/16/24 - A care plan documented that R4 was high risk for falls related to impaired gait/balance. 11/15/24 - A new order documented R4 was a total assist for transfer and to be transferred with two staff using a Hoyer lift. 12/4/24 - R4's annual MDS documented a BIMS score of 15, revealing an intact cognitive state. R4 was documented with impairments on both…
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 · D2025-03-06 · tag F0773 — isolatedProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, it was determined, for two (R442 and R9) out of three residents sampled for laboratory services, the facility failed to promptly notify the ordering medical practitioner of abnormal laboratory results. Findings include: Cross refer F684 1. Review of R422's clinical record revealed: 5/23/24 - R422 was admitted to the facility with diagnoses that included Parkinson's disease, history of a stroke affecting the right dominent side and dementia. 6/13/24 - A physician's order was written for a urinalysis with a culture and sensitivity. 6/16/24 - The results were faxed to the facility supervisor's office which revealed R422's urine culture had a positive growth of enterococcus casseliflavous (a type of bacteria) greater than 100,000 cfu/ml, indicating a urinary tract infection. 3/5/25 - A review of R422's clinical record revealed lacked evidence of the laboratory results and notification of provider. 3/5/25 10:34 AM - During an interview, E2 (DON) stated that all lab results are faxed to the nurse supervisor's office. If a lab result is positive 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.
Show the remaining 9 citations
- Potential for harm · E2024-04-25 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 interview, record review, and policy review, the facility failed to ensure resident, and resident's representatives were notified at time of discharge of the location and reason for the discharge for a sample of four of four residents (Resident (R)13, R19. R12 and R39) reviewed for hospitalization. As a result of this deficient practice, residents had the potential for location of residents not known to families or resident representatives. Findings include: 1. Review of R13's admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 04/26/22 and readmission on [DATE] with medical diagnoses that included chronic obstructive pulmonary disease and adult failure to thrive. Review of R13's Significant Change Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 01/17/24, revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating R13 was severely cognitively impaired. Review…
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 before2024-04-25 · 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 protect two of three residents (Resident (R) 51, R63), reviewed for abuse, when facility nursing staff, a Certified Nurse Aide (CNA)4 used profanity toward R51 during care. In addition, when R39 sat on R63's bed and pushed down on R63's chest with his hands. Failure to protect residents from abuse has the potential to result in injury to residents. Findings include: 1. Review of R51'sadmission Record located in electronic medical record (EMR) under the Profile tab indicated R51 was admitted on [DATE] with diagnoses which included unspecified dementia, unspecified severity with agitation, and generalized anxiety. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/03/23, found in the EMR under the MDS tab indicated a Brief Interview for Mental Status (BIMS) score of five out of 15, indicating a severe cognitive deficit. Review of the Investigation File, dated 01/19/24 indicated a written statement…
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 · D2024-04-25 · 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 observation, interviews, record review, policy and procedure review, the facility failed to follow infection control procedures during a dressing change for one of three residents (R)4 reviewed. Specifically, the Registered Nurse (RN)1 failed to clean the over the bed table or place a barrier on the table before placing clean wound supplies on the table. Also, RN1 failed to perform hand hygiene when she returned to the room after obtaining a dressing from the treatment cart. The failure created the potential for an infection to develop in R4's wounds. Findings include: Review of the facility's policy titled Skin Integrity/Wound Care dated 03/08/23, revealed .A resident with skin impairment will receive treatment and services, consistent with professional standards of practice, to promote healing . Review of the facility's procedure titled Wound Treatment Competency Audit provided by the Administrator on 04/25/24 revealed the following criteria for all nurses to utilize .7. Assembles necessary equipment…
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 · D2023-04-25 · 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 and record review it was determined that for two residents (R19 and R49) out of two residents reviewed for accommodation of needs, the facility failed to ensure that the residents' call device were within reach. Findings include: 1. Review of R39's clinical record revealed: 3/21/23 - An annual MDS reflected R39 was totally dependent on staff for performance of ADL's, except for bed mobility that required extensive assistance. 4/21/23 8:54 AM - An observation of R39 in their room after returning from breakfast. R39 was seated in the wheelchair and the call device was on the nightstand and not within reach. 2. Review of R19's clinical record revealed: 3/21/23 - R19's Quarterly MDS Assessment documented R19 required extensive assist of two for bed mobility and had an impairment to one side of the upper and lower body. 4/19/23 12:54 PM - During an initial observation and interview, R19 was observed lying in bed and the call device was on the far-right side of the nightstand next to the bed. R19 revealed he had weakness from a stroke and could not reach the call…
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 · D2023-04-25 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
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 (R56) out of four residents reviewed for activities of daily living (ADL's), the facility failed to complete a significant change MDS (Minimum Data Set) assessment when R56 had a significant decline in functional and mental status. Findings include: Review of R56's clinical record revealed: 10/26/22 - R56 was admitted to the facility with dementia. 11/1/22 - R56's admission MDS documented that R56 required supervision of one staff member for bed mobility, transfers, eating, ambulation (walking) and required limited assist of two staff members for toileting. R56's BIMS (Brief Interview for Mental Status) assessment documented three out of fifteen correct answers during the interview. 1/31/23 - R56's quarterly MDS documented that R56 required extensive assistance of two staff members for bed mobility, transfers and toileting, supervision of one staff member for eating, and was non-ambulatory (unable to walk). R56's was not able to complete the BIMS interview due to a decline in his cognition. R56 required a…
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 · D2023-04-25 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, record review and interview, it was determined that for one (R44) out of one resident reviewed for dental, the facility failed to have a MDS (Minimum Data Set) assessment that accurately reflected R44's missing teeth. Findings include: Review of R44's clinical record revealed: 9/21/22 - R44 admitted to facility. 2/28/23 - A significant change MDS assessment documented that R44 had no broken or loosely fitting full or partial denture. 4/19/23 10:11 AM - During a random observation R44 had missing upper, front teeth. 4/21/23 10:03 AM - During an interview, E5 (RN, unit manager) stated they (the facility) knew about the resident's missing partial denture plate since his admission. In addition, E5 confirmed that the oral assessment section for R44's MDS was a mistake. 4/25/23 at 1:15 PM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).
- Potential for harm · D2023-04-25 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review it was determined that for one (R31) out of five residents reviewed for unnecessary medications the facility failed to provide evidence that the attending physician reviewed irregularities/recommendations documented on the monthly Medication Regimen Review (MRR). Findings include: The facility policy for MRR last updated 1/2023, indicated that, all recommendations shall be acted upon within 30 calendar days. For those issues that require physician intervention, the attending physician either accepts and acts upon the report and recommendations or rejects all or some of the report and should document his or her rationale of why the recommendation is rejected in the residents medical record. Review of R31's clinical record revealed: 6/14/22 - The MRR documented the following recommendation in a pharmacy consultant note, to the physician. This resident has been taking an antidepressant at a dosage of 150 milligrams daily. Please evaluate the current dose and consider a dose reduction. The signature line for the attending physician acknowledgement…
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 · D2023-04-25 · tag F0943 — isolatedGive their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and review of facility documentation as indicated, it was determined that the facility failed to ensure that the required trainings on abuse, neglect and exploitation were completed as required for one (E8) out of ten randomly sampled staff members. Findings include: Review of the facility submitted staff training records revealed: 11/8/20 - E8 (CNA) began working at the facility. E8 had no documented date of completion of abuse training. 4/24/23 12:25 PM - During an interview, E1 (NHA) confirmed the findings. 4/25/23 1:15 PM- Findings were reviewed during the Exit Conference with E1 (NHA), and E2 (Interim DON).
- Potential for harm · D2023-04-25 · tag F0947 — failed to train nurse aides adequately — isolatedEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and review of facility documentation as indicated, it was determined that the facility failed to provide required in-service training (12 hours per year) for three (E8, E9, and E10) out of three CNA's reviewed additionally the facility failed to ensure these three CNA's had trainng on dementia management and care of the cognitively impaired. Findings include: 4/24/23 12:18 PM - Review of the facility submitted staff training worksheet revealed a lack of evidence of dementia training for the CNA's sampled. The space for CNA dates of training and hours had a line drawn through the space for E8, E9 and E10. Indicating that none of the 12 hours were completed. 4/24/23 12:25 PM - During an interview with E1 (NHA), it was reported that the facility was unable to provide evidence of dementia training and the hours completed because that information was unable to be located after the prior human resources staff was released from the facility's employment. 4/25/23 1:15 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2 (Interim DON).
“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
$118,757 in federal fines across 2 penalties.
- $86,920 — penalty dated 2026-03-12
- $31,837 — penalty dated 2025-03-06
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.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| GROFF, SANDRA | Individual | W-2 MANAGING EMPLOYEE | since 08/27/2012 |
| PETERSON, WILLIAM | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR | since 03/08/2010 |
| ERHART, CAROL | Individual | CORPORATE DIRECTOR | since 10/20/2020 |
| CANNON, JOHN | Individual | CORPORATE OFFICER | since 12/19/2022 |
| SATTERLY, LISA | Individual | CORPORATE OFFICER | since 05/01/2022 |
CMS files one row per role, so the 6 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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 085051. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-12, 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.