Delaware Oaks Center for Rehabilitation and Nursin

Inspectors wroteBased on observation, interview, and record review conducted during a Complaint Investigation (2598732) during the Standard survey completed on 09/19/2025, the facility failed to protect residents from resident-to-resident sexual abuse for one (1) (Resident #12) of three (3) residents reviewed. Specifically, Resident #12 was touched inappropriately by Resident #51 and both residents lacked the ability to consent. The finding is: The policy titled Prevention, Investigation & Reporting Resident Abuse, Mistreatment, Injury of Unknown Source, Neglect & Misappropriation of Resident Property Effective 5/2024 and last reviewed 7/2024 documented that it was the facility's policy to prevent sexual abuse, and documented sexual abuse was defined as non-consensual sexual contact of any type with a resident. Resident #51 had diagnoses which included dementia, depression, and type 2 diabetes mellitus. [...]

Inspectors wroteBased on interview and record review conducted during Complaint investigation (2598732) during the Standard Survey completed on 09/19/2025, the facility did not ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse, to the administrator and to other state officials (including to the State Survey Agency) for two (2) (Residents #12 and #51) of three (3) residents reviewed. Specifically, the Administrator was notified of an allegation of resident-to-resident abuse and it was not reported to the State Agency within the required time frame. [...]

Inspectors wroteBased on observation, interview, and record review completed during a complaint investigation (#NY000373627), the facility did not ensure provision of a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of three residents reviewed for infection control practices. Specifically, Resident #1 was on enhanced barrier precautions (interventions designed to reduce transmission of multi-drug-resistant organisms (MDRO) including gown and glove use during high contact resident care activities) and staff did not wear proper personal protective equipment (gowns) during hands-on care while dressing, changing briefs, changing linens and performing wound care. The finding is: [...]

Inspectors wroteBased on observation, interaview and record review conducted during a Standard survey completed on 8/9/24, it was determined that the facility did not ensure that they maintained an effective pest control program so that the facility is free of pests and rodents. Specifically, two (Units 2 & 3) of two Resident Units and the Main Kitchen had issues with insects including house flies, spiders, and fruit flies.

Inspectors wroteBased on observation, interview, and record review conducted during Complaint investigations (#NY00336247 and #NY00319578) during a Standard survey completed on 8/9/24 the facility did not ensure that housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior were provided for one (Unit 3) of two resident units. Specifically, the facility roof was in disrepair and actively leaking resulting in stained and wet ceiling tiles. Additionally, there were walls and floors in disrepair, urine odors, a soiled privacy curtain and a broken window.

Inspectors wroteBased on observation, interview, and record review conducted during a complaint investigation (Complaint #NY00330109) during the Standard survey completed on 8/9/24, the facility did not ensure the resident's right to be free from abuse for one (Resident #72) of 7 residents reviewed for abuse. Specifically, Resident #72 wandered into Resident #61's room on two separate occasions where a resident-to-resident altercation occurred that resulted in minor injuries to Resident #72. Additionally, care plan interventions (stop signs in doorway) to keep Resident #72 out of the room, were not in place. The finding is: The policy and procedure titled Abuse Prohibition Protocol, Types of Abuse, Response/Reporting dated 1/24 documented every resident has the right to be free from abuse and the facility would do all that is in their control to prevent such occurrences. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 8/9/24, the facility did not ensure that when the use of a restraint was indicated, the facility used the least restrictive alternative for the least amount of time for one (Resident #76) of one resident reviewed. Specifically, the resident's seatbelt restraint was not released every two hours as ordered. The finding is: The policy and procedure titled Use of Restraints dated 1/24 documented a physical restraint was defined as any manual method or mechanical device attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement. The opportunity for motion and exercise is provided for a period of not less than 10 minutes during each two hours of restraint use. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Complaint investigation (NY00345819) during a Standard survey completed on 8/9/24, it was determined the facility did not ensure that the resident's person-centered care plan was implemented to meet the resident's medical and nursing needs for two (Residents #61 and #63) of nine residents reviewed. Specifically, the residents did not have a stop sign/s across their doorway to deter other residents from entering their room as planned. The finding is: The policy and procedure titled Care Plan, Comprehensive Person-Centered dated 1/24 documented that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 8/9/24, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing for one (Resident #49) of one resident reviewed. Specifically, the Physician Wound Consultants recommendations for an air mattress were not implemented. The finding is: The facility policy and procedure titled Consultations, last revised 1/24, documented the facility is responsible to provide consultation services for any residents as needed. The facility assumes responsibility for obtaining services that meet professional standards and principles that apply to professionals providing services in such a facility, and the timeliness of the services. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 8/9/24, the facility did not ensure that a resident with limited range of motion received the appropriate treatment and services to prevent further decrease in range of motion for one (Resident #5) of one resident reviewed for positioning and mobility. Specifically, Resident #5 had a contracture (loss of joint mobility) and was not provided a device to prevent further contracture. The finding is: The facility policy and procedure titled Contracture Management, last revised on 1/24, documented the facility will engage residents as appropriate in contracture management interventions to improve, maintain and prevent the deterioration of mobility of joints, flexion (bending of a joint) and extension of extremities. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Complaint investigation (#NY00330919) during the Standard Survey completed on 8/9/24, the facility did not ensure each resident received food that accommodated their allergies, intolerances, and preferences for one (Resident #89) of one resident reviewed. Specifically, Resident #89 received a meal tray with foods that did not accommodate their documented preferences.

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed 3/24/23, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one Kitchen had issues: dirty hoods over the ovens/stoves; the light over the stove was out, pipes along the ceiling had a build- up dust; the griddle was soiled with a thick layer of black a greasy dried substance; the wall next to the griddle and behind the ovens/stoves and floor under the ovens/stove were soiled with a black greasy substance; floors throughout the kitchen were soiled with debris black greasy substance; the ice cream freezer had ice build-up; garbage cans were over- flowing with garbage and had no lids. There were multiple crates of outdated milk in the refrigerator; [...]

Inspectors wroteBased on observation, interview, and record review during the Standard survey completed on 3/24/23, the facility did not maintain the resident call bell system in working order. Specifically, call bells in resident rooms, resident bathrooms and shower rooms did not activate the call light above the residents' room doors and did not activate the master station located at the Nurses' Station. This affected one (2nd floor) of two resident units. This involves Residents #35, 59 and 54. The finding is: The policy and procedure titled, Answering the Call Light reviewed 2/2023, documented a general guideline was to report all defective call lights to the nurse supervisor promptly and nursing must notify maintenance department of the defective call light. [...]

Inspectors wroteBased on observation, record review, and interview conducted during a complaint investigation (Complaint #NY00298668) during the Standard survey completed on 3/24/23, the facility did not ensure residents had the right to be free from sexual abuse for four (Resident #s 1, 21, 67 and 246) of 11 residents reviewed for abuse. Specifically, the facility did not ensure Resident #246 did not engage in non-consensual sexual contact with Resident #1. Resident #246 was found touching Resident #1's exposed genitals. Additionally, Resident #67 had non- consensual contact with Resident #21 and was found touching Resident #21 on their breast and inner thigh in the dining room.

Inspectors wroteBased on interview and record review conducted during a complaint investigation (NY00298668) completed on a Standard survey completed 3/24/23, the facility did not ensure that all alleged violations including abuse are reported immediately, but not later than 2-hours after the allegation is made to the appropriate officials (including the State Survey Agency). Specifically, two (#1 and #246) of eleven residents reviewed for abuse were involved in an allegation of sexual abuse and was not reported timely to the New York State (NYS) Department of Health (DOH) as required. The finding is: [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey, completed on 3/24/23, the facility did not ensure that a resident's drug regimen was free from unnecessary psychotropic medications for one (Resident #70) of five residents reviewed for antipsychotic medications. Specifically, an antipsychotic (AP) medication was restarted without behavioral documentation or psychotic features to support its use and physician progress notes documented the resident was stable with no indication to restart psych meds. Additionally, there was lack of monitoring for side effects after the medication was initiated. The finding is: [...]

Inspectors wroteBased on observation, interview, and record conducted during the Standard survey completed on 4/14/21, the facility did not ensure that each resident is treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, one (Resident #340) of one resident reviewed for dignity had issues involving, resident exposure and incontinent care provided by staff in the dayroom in clear view of staff, residents, and visitors. Additionally, meals were served to the resident on a bare mattress that was placed directly on the floor in the dayroom and the resident was not provided with a call light/bell.

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 4/14/21, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent infection for one (Resident #17) of two residents reviewed. Specifically, there was lack of weekly pressure ulcer assessments by a qualified person and the Treatment Administration Records (TAR) were not accurately documented.

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 04/14/21, the facility did not ensure that residents who require dialysis, received services consistent with professional standards of practice. Specifically, one (Resident #62) of one resident reviewed for dialysis had an issue involving the lack of ongoing communication and collaboration by the facility staff and the staff of the dialysis center regarding dressing changes to the AVF (arteriovenous fistula) access site (a tube or device surgically implanted to create an artificial connection between an artery and a vein) resulting in the pressure dressing not being removed per physician order. The finding is: [...]

Inspectors wroteBased on observation, interview and record review conducted during the Standard survey completed on 4/14/21, the facility did not ensure that residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record and PRN (as needed) orders for psychotropic drugs are limited to fourteen days and the Physician believes that it is appropriate for the PRN order to be extended beyond fourteen days should document the rationale in the medical record and indicate the duration of the PRN order. One (Residents #22) of five residents reviewed for unnecessary medications had an issue involving the lack of physician documentation supporting the continued use of the PRN psychotropic medication (Xanax - medication used to treat anxiety) beyond fourteen days. The finding is: [...]

Inspectors wroteBased on observation, record review and interview during the Standard survey completed on 4/14/21, the facility did not ensure all drugs and biologicals were labeled in accordance with currently accepted professional principles including expiration date, were stored in locked compartments, and that controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse were stored in separately locked, permanently affixed compartments for 3 of 4 medication storage areas. Specifically, the second floor medication room was left unlocked and contained unsecured/ unattended medications, the second floor Team 1 medication cart contained expired over the counter (OTC) medications and an undated insulin pen for Resident #66. [...]