Jeanne Jugan Residence
185 Salem Church Road, Newark, DE 19713 · Non profit - Corporation · 40 certified beds · (302) 368-5886 Medicaid only — no Medicare
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no harm-level citations in the current inspection record
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (29% vs 45% nationally) — better care continuity
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 3 of 5 |
| Long-stay residentspeople who live here | 3 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 5 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 | 19.5% | 12.7% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.5% | 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 | 14.8% | 2.1% | 2.0% | worse |
| 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 | 11.1% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 21.0% | 13.6% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 23.5% | 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 | 0.0% | 3.5% | 4.7% | check this* — see note marked star below the table |
| Long-stay residents with worsening bladder/bowel control | 19.4% | 20.2% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.6% | 10.7% | 17.1% | better |
| Long-stay hospitalizations per 1,000 resident days | 3.06 | 1.81 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.40 | 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 0.21 therapist hours per resident per day in 2026Q1 — more than 24% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% 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 — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| 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 — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| 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 — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
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 40 beds and averages 20.8 residents a day — about 52% occupied, or roughly 19 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 6.78 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.39 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.74 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 5.65 hrs/resident/day on weekends vs 7.24 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 1.71 to 0.62 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 29% is below 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.
14 citations, most serious first — scroll within the box to see all.
- Potential for harm · F2026-04-10 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and document review, it was determined that the facility failed to comply with the Delaware Food Code Certified Food Protection Manager Requirements. Findings include:Delaware Food Code:2-102.12 Certified Food Protection Manager(A) At least one employee, the PERSON IN CHARGE at the time of inspection, shall be a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM.4/7/26 - During the survey of the facility at approximately 10:00 AM, an interview with E8 (Dining Services Manager), revealed that there was only one CFPM. E8 works on Tuesdays and Thursdays and for the other days, there is not a CFPM present. Today 4/7/26 E8 left at 1:00 PM.4/7/26 - During an interview with E8 at approximately 11:00 AM, the findings were confirmed.4/10/26 3:10 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (CEO) during the Exit Conference.
- Potential for harm · Fcited before2026-04-10 · 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 and interview, it was determined that the facility failed to comply with Delaware Food Code storage and sanitation procedures.Delaware Food Code:3-305.11 Food Storage.(A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD:(1) In a clean, dry location;(2) Where it is not exposed to splash, dust, or other contamination; and(3) At least 15 cm (6 inches) above the floor.4/7/26 - During the survey of the facility at approximately 10:00 AM, an observation of the outdoor walk-in freezer revealed three turkeys were lying on the floor of the outdoor walk-in freezer.4/7/26 - During an interview with E8 and E6 (Cook) at approximately 11:00 AM, the findings were confirmed.7-204.11 Sanitizers, Criteria.Chemical SANITIZERS, including chemical sanitizing solutions generated on-site, and other chemical antimicrobials applied to FOOD-CONTACT SURFACES shall:(A) Meet the requirements specified in 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (Food-contact…
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 · D2026-04-10 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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 (R3) out of one resident reviewed for ROM the facility failed to ensure devices to prevent further decline in ROM were applied. Findings include: The facility policy on restorative nursing last updated December 2025 indicated, The interdisciplinary team is responsible for working with residents to assist them in adjusting to their disabilities, to use their prosthetic devices .Review of R3's clinical record revealed:8/22/24 - A physician's orders was written for R3 to receive a short splint to the left hand in the morning and off before supper. If splint is not tolerated, then apply stretch gauze wrap in a figure 8 pattern from the wrist and around the palm.3/25/25 - An initial evaluation and treatment for physical therapy documented that R3 had severe left-hand contracture.1/13/26- An annual MDS assessment documented that R3 had impairments to both upper extremities (hands) and moderate cognitive impairment. 1/28/26 - R3's care plan for Parkinson's Disease was reviewed by the facility's interdisciplinary team.…
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 · D2026-04-10 · tag F0730 — isolatedObserve each nurse aide's job performance and give regular training.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and review of facility documentation, it was determined that the facility failed to ensure that a performance review was completed at least every twelve months for one (E19) out of five sampled employees. Findings include:4/10/26 10:00 AM - Review of the staff performance evaluations revealed that E19 (CNA) had a hire date of 3/29/22. A record review revealed lack of evidence of a performance evaluation for the past year and was confirmed by E4 (HR). 4/10/26 12:00 PM - Finding was discussed with E1 (NHA)4/10/26 3:10 PM - Finding was reviewed with E1 (NHA), E2 (DON) and E3 (CEO) during the Exit Conference.
- Potential for harm · F2024-03-21 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 and interview it was determined that the facility failed to have measures in place to prevent the growth of Legionella and other opportunistic waterborne pathogens when they did not identify areas in the facility where Legionella could grow and spread and failed to establish measures for monitoring of water testing. Findings include: The facility policy for the Legionella Water Management Program, last updated July 2017, indicated As part of the infection prevention and control program, our facility has a water management program .The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaires disease. The water management program includes the following elements: A detailed description and diagram of the water system in the facility .identification of areas in the water system that could encourage growth and spread of Legionella and other water borne bacteria. The water management program will identify measures that are monitored. 8/19/21- The facility…
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 · D2024-03-21 · 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
Based on interview and review of other facility documentation, it was determined that the facility failed to immediately report to the State Agency for one (R128) out of two residents reviewed for abuse. Findings include: Review of R128's clinical record revealed: 8/23/23 - Review of the facility investigation of an alleged physical abuse revealed the following: - On 8/23/23 2:15 PM, E2 (DON) informed E9 (SW) that R128 reported E15 (CNA) beat her up in her room. E20 (RN) performed a physical check of R128 ' s body from head to toe and reported not finding any bruises that would substantiate R128's allegation. - On 8/23/23 2:50 PM, E9 went to R128's room to discuss the incident with R128. E9 spoke briefly with R128 and inquired about R128's well-being and if R128 wanted to discuss anything. R128 said she was tired and did not feel like having a visit at this time. 8/25/23 11:25 AM - A report was submitted to the State Agency by E4 (ADON). 3/20/24 1:03 PM - During an interview E9 said, .(E3) reported the allegation of abuse to me. In, addition E9 said, .I believe the reporting time…
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 · D2024-03-21 · 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 — an excerpt from the official record, may be distressing
Based on record review and interview it was determined that the facility failed to ensure annual completion of abuse training for two (E18 and E19) out of eight staff reviewed. Findings include: The facility policy on abuse last updated 4/2023 indicated, Staff and volunteers will receive education about resident mistreatment, neglect, and abuse, including injuries of unknown source exploitation, and misappropriation of property upon first employment and annually after that . 3/20/24 10:01 AM - E5 (RN) Inservice Director was provided a worksheet requesting dates of staff training. 3/21/24 Review of the staff training worksheet provided revealed: - E18 last received training for abuse, neglect, and exploitation on 10/14/21. - E19 last received training for abuse neglect, and exploitation on 8/18/22. During an interview on 3/21/24 at 10:49 AM, E5 (RN) Inservice Director, confirmed the finding, and stated, We send out an email blast for them to complete the trainings but they don't return them. Findings were reviewed with E1 (NHA) and E3 (DON) during the exit conference on 3/21/24 at…
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 · E2022-10-27 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 reviews, interviews and review of the facility policy, it was determined that the facility failed to ensure that medications were administered in accordance with the resident care plan and per Physician orders for two (R1 and R30) out of 12 sampled residents. Findings include: Review of the facility policy entitled Medication, Administration, last reviewed August 2018, stated, .20. If medication is ordered but not present: a. Reasonable time for new medications is twenty-four (24) hours if ordered after 4 p.m. or arrival in the Pharmacy Tote during the third (3rd) shift . b. If any discrepancies, phone the pharmacy to inform of not receiving the medication. The nurse must notify their supervisor . Cross refer to F755 1. R30's clinical record revealed: R30 was admitted to the facility in 2018. 4/12/22 - Review of R30's care plan included a potential nutritional problem related to GERD (gastroesophageal reflux disease or acid reflux), including medication as ordered. 6/11/22 - A physician's order was written for Nexium DR (delayed release) 40 mg by mouth every morning…
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 · E2022-10-27 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, it was determined that the facility failed to provide routine pharmaceutical services for acquiring and receiving medication to meet one residents (R30) needs out 12 sampled. The facility failed to make any attempts to call or contact the pharmacy when R30 ran out of Nexium. As a result, R30 did not receive her Nexium for 9 days from 8/15/22 through 8/23/22. It was unclear whether Nexium was a stock med in the facility at the time and whether it was available to be given in the interim. Findings include: R30's clinical record revealed: Review of the facility policy entitled Medication, Administration, last reviewed August 2018, stated, . 20. If medication is ordered but not present: a. Reasonable time for new medications is twenty-four (24) hours if ordered after 4 p.m. or arrival in the Pharmacy Tote during the third (3rd) shift . b. If any discrepancies, phone the pharmacy to inform of not receiving the medication . Cross refer to F684, example 1 1. R30's clinical record revealed: 6/11/22 - A physician's order was written for Nexium DR…
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 before2022-10-27 · 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 — the official record, unedited, may be distressing
Based on observations and interviews, it was determined that the facility did not store food and utensils in a sanitary manner. Findings include: The following were observed on 10/18/22 from 1:10 PM to 2:10 PM during the initial kitchen tour: 1. The ceiling tile in the fume hood area was loose. 2. The dry storage area had uncovered fluorescent light bulbs. Findings were reviewed and confirmed with E19 (Food Service Director) on 10/18/22 at approximately 2:00 PM. 10/27/22 at 3:30 PM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).
- Potential for harm · D2022-10-27 · 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
Based on record review, policy review, observations and interview, it was determined that for one (R29) out of 12 sampled residents, the facility failed to ensure that R29 received respiratory care consistent with her physician orders. Findings include: Review of the facility's policy: Oxygen Therapy, Nasal Cannula revised 8/2018, revealed the following: . Policy Purpose: To improve oxygenation and provide comfort to residents experiencing respiratory difficulties. Policy Procedure: . 6. Attach pre-filled humidifier bottle to flow meter if using concentrator . 7. Attach nasal cannula/face mask tubing to humidifier bottle, if using concentrator . Review of R29's clinical record revealed: 8/27/18- R29 was admitted to the facility with multiple diagnoses including Chronic Obstructive Pulmonary Disease (COPD). 7/18/22- A physician order was written for Oxygen therapy to be administered to R29 via nasal tubing (nasal cannula) related to COPD with an acute exacerbation (increase of symptoms). 7/19/22- A physician order was written to change the Oxygen tubing and the humidifier every two…
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 · D2022-10-27 · 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 review of the Manufacturers' recommendations as indicated, it was determined that the facility failed to ensure that a prescribed drug and biological currently in use must be labeled with the open/discard date to ensure that they are used and disposed of according to the Manufacturers' recommendations. Findings included: Tubersol is a diagnostic biological used to detect Tuberculosis (a potentially serious infectious disease that mainly affects the lungs). According to the Tubersol Manufacturer's package insert (undated), a vial of Tubersol that was opened for 30 days should be discarded. Azelastine is a prescribed medication used to treat allergic rhinitis (stuffy nose/congestion). The Azelastine's Manufacturer's package insert (revised 9/2018) stated, The correct amount of medication in each spray cannot be assured . after 200 sprays have been used, even though the bottle is not completely empty. The bottle should be discarded after 200 sprays have been used . 10/26/22 at 10:45 AM - Observation of Medication Storage with E11 (RN) 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.
- No harm found · C2022-10-27 · tag F0623 — widespreadProvide 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
2. R30's clinical record revealed: R30 was admitted to the facility in 2018. 5/29/22 to 6/10/22 - R30 was hospitalized . 10/25/22 at approximately 3:00 PM - E2 (DON) was interviewed and asked if the Ombudsman was notified of R30's transfer to the hospital. E2 stated, I don't know. 10/25/22 at approximately 3:10 PM - E5 (Social Services) was interviewed and confirmed that she didn't know that the Ombudsman was supposed to be notified when residents were transferred to the hospital or discharged . Based on interviews and clinical record reviews, it was determined that for three out of four sampled residents (R1, R5 and R30) reviewed for hospitalization/discharge, the facility failed to provide notice of the hospital transfers to the Ombudsman. Findings included: 1. R5's clinical record revealed: 4/26/22 to 4/29/22 - R5 was hospitalized . 10/27/22 at 9:06 AM - During an interview, E5 (SW) confirmed that the Ombudsman's Office was not notified of R5's April 2022 hospitalization. 3. Review of R1's clinical record revealed: 8/22/14- R1 was admitted to the facility. 8/18/22 to 8/23/22 - R1…
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.
- No harm found · C2022-10-27 · tag F0732 — widespreadPost nurse staffing information every day.
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 and interview, it was determined that the facility failed to post the required nurse staffing information requirement in a prominent place, readily accessible to residents and visitors for two out of two nursing units. Findings include: 1st Floor Observation 10/27/22 8:50 AM - An observation on the 1st floor Holy Family nursing station, revealed that nursing staffing data was posted on the magnetic white board. The posting lacked the licensed nurses and CNA (Certified Nurse Aide) hours and the resident census of the day. 2nd Floor Observation 10/27/22 8:55 AM - An observation on the 2nd floor St. (saint) [NAME] nursing station revealed that nursing staffing data was posted on the magnetic white board. The posting lacked the licensed nurses and CNA hours and the resident census of the day. Lobby Hallway Observation 10/27/22 9:00 AM - An observation in the corner of the lobby hallway revealed that nursing staffing data was posted on a legal sized paper and the Surveyor could not easily read…
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
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
What families pay in DE
CMS lists this home as Medicaid-certified only — it can accept Medicaid for long-term care, but it is not Medicare-certified, so Medicare will not pay for a short rehabilitation (“skilled nursing”) stay here. 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 08A006. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-10, 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.