5651 Limestone Road, Wilmington, DE 19808 · New Castle County · (302) 239-8583
177 certified beds, about 171 residents a day · For profit - Individual · Medicare and Medicaid since 1988
CMS Care Compare ratings, data as of September 1, 2026 · CCN 085033 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on September 10, 2024, inspectors cited 26 health deficiencies (the Delaware average is 10.9, the national average 9.2).
Of 97 health citations since May 2022, 6 were rated as actual harm or immediate jeopardy to residents (3 immediate jeopardy).
CMS lists 2 fines totaling $484,596 in the last three years; the largest was $263,388, and the latest is dated September 10, 2024.
Nurses and nurse aides worked 3.88 hours per resident per day, against 4.35 across Delaware and 3.86 nationally. Registered nurses accounted for 0.53 of those hours.
45.3% of nursing staff left within the year CMS measured (Delaware average 41.3%).
CMS links it to Lifeworks Rehab, an affiliated group of 64 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 97 health citations on file.
Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that for two (R29 and R30) out of three residents sampled for quality of care, the facility failed to ensure that R29 and R30 were assessed by a Registered Nurse after it was identified that they had fallen to the floor. The facility also failed to ensure that the post fall documentation was completed, and the physician and responsible parties were notified in a timely manner. Due to the facility's corrective measures completed on 5/11/26, the facility was notified that R29's and R30's incidents were past non-compliance.
Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that for one (R2) out of three residents sampled for accidents, it was determined that the facility failed to ensure that R2 received adequate supervision and assistive devices to prevent accidents to the extent possible.
Inspectors wroteBased on observation and interview, it was determined that the facility failed to promote resident dignity as evidenced by observations during dining and entering resident rooms without permission.
Inspectors wroteBased on record review and interview, it was determined that for two (R22, R153) out of 37 residents reviewed for care plans, the facility failed to develop a comprehensive person-centered care plan for each resident that addressed each resident's medical needs.
Inspectors wroteBased on observation, record review, and interview, it was determined that for two (R111 and R110) out of 37 residents sampled for investigation, the facility failed to ensure that residents received care and services in accordance with professional standards of practice, the comprehensive person centered care plan, and physician orders. For R111 the facility failed to implement discharge orders for vascular surgery follow up appointment for a surgical wound. For R110 the facility failed to collaborate with Hospice for the development, implementation, and revision of the coordinated plan of care for a resident receiving hospice services.1. R111's clinical record revealed: 7/7/25 - R111 was admitted to the facility with diagnoses including, but not limited to, an infection of the amputation stump on the left lower extremity. [...]
Inspectors wroteBased on observation and interview, it was determined that for eight out of eight days on survey, the facility failed to post nurse staffing information on a daily basis that included, but was not limited too, the resident census and the total number of hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift.
Inspectors wroteBased on interview, review of clinical records including two incidents involving significant medication errors and other documentation as indicated, it was determined that for 29 out of 29 licensed nurses reviewed, the facility failed to have a system/process in place to ensure each licensed nurse had competencies and skills sets necessary to care for current residents' needs. - On 7/6/24, E43 (RN) administered another resident's medications to R322, which resulted in a serious adverse outcome. R322 required emergent admission to the ICU for treatment and monitoring. The facility failed to ensure E43 had a medication administration competency and skill set validated during his orientation. [...]
Inspectors wroteBased on observation, interview, review of clinical records and other documentation as indicated, it was determined that for one (R322) out of three residents reviewed for hospitalizations and three (R22, R33 and R95) out of nine residents reviewed for medication administration, the facility failed to ensure that residents were free of significant medication errors. On [DATE], R322 was administered R144's prescribed medications. As a result, R322 was emergently sent to the hospital requiring treatment and monitoring in the Intensive Care Unit (ICU). The facility's multiple failures involved in this incident had the potential to cause a serious adverse outcome or death to R322 with respect to receiving another resident's multiple blood pressure medications and diabetic medications. Due to the failures, an Immediate Jeopardy (IJ) was called on [DATE] at 2:08 PM. [...]
Inspectors wroteBased on observation, interview, and record review, it was determined that for six (R90, R111, R118, R165, R170 and R31) out of six residents reviewed for care plans, the facility failed to develop and implement a comprehensive person-centered care plan. For R90, R111, R118, R165 and R170, the facility failed to develop care plans based on assessmnet to restore and maintain their bladder and bladder continence to the extent possible. For R31, the faciliy failed to develop a care plan to address R31's right hand contracture and use of the right hand palm guard.
Inspectors wroteBased on observations, interviews, and record reviews, it was determined that for five (R90, R111, R118, R165 and R170) out of five residents reviewed for bowel and bladder assessments, the facility failed to conduct bowel and bladder assessments to develop an individualized care plan to restore and maintain their bladder and bladder continence to extent possible.
Inspectors wroteBased on random observation and interview, it was determined that the facility failed to provide food to residents taking into consideration their preferences.
Inspectors wroteBased on observation and interview it was determined that for four (R21, R90, R119 and R172) randomly observed residents during dining observations, the facility failed to ensure food was served was palatable and at appetizing temperatures.
Inspectors wroteBased on observation and interview it was determined that for three out of three units reviewed the facility failed to ensure food items in the nourishment refrigerators were labeled and dated.
Inspectors wroteBased on interview and review of facility documentation, it was determined that for two (E57 and E58) out of five nursing staff reviewed, the facility failed to ensure that the required QAPI (Qualify Assurance And Performance Improvement) training was completed.
Inspectors wroteBased on interview and review of facility documentation, it was determined that for two (E57 and E58) out of five nursing staff reviewed, the facility failed to ensure that the required training on Compliance and Ethics Program was completed.
Inspectors wroteBased on interview and review of facility documentation, it was determined that for five (E43, E55, E56, E57 and E58) out of five nursing staff reviewed, the facility failed to ensure that the required Behavioral Health training was completed.
Inspectors wroteBased on observation, interview, and record review, it was determined that for one (R422) out of two residents reviewed for dignity, the facility failed to ensure that the urinary collection container was placed in a privacy bag.
Inspectors wroteBased on interview and review of clinical records and other documentation as indicated, it was determined that for two (R176 and R344) out of seventeen (17) residents reviewed for abuse, the facility failed to report alleged violations involving abuse no later than 2 hours after each allegation was made.
Inspectors wroteBased on interview and record review, it was determined that for one (R320) out of four residents reviewed for accidents and one (R31) out of one resident reviewed for care planning, the faciliy failed to review and revise the residents' care plans.
Inspectors wroteBased on observation, interview and record review it was determined that for one (R105) out of seven residents reviewed for activities of daily living (ADLs), the facility failed to ensure that R105 received the treatment/services to prevent further avoidable reduction of ROM and mobility. The facility lacked evidence that the palm device was applied to prevent further worsening of contractures to R105's left hand as recommended.
Inspectors wroteBased on interview and record review, it was determined that for three (R324, R170 and R270) out of 14 residents reviewed for accidents, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents. For R324, the facility failed to transfer R324 with a hoyer lift per the plan of care. For R170, the facility failed to provide supervision while care was being provided by a staff member. For R270, the facility failed to put the wheelchair foot rests on prior to transportation.
Inspectors wroteBased on observation, interview, and record review, it was determined that for one (R111) out of two residents reviewed for nephrostomy catheter, the facility failed to provide safe and sanitary urinary catheter care to prevent urinary infections to the extent possible.
Inspectors wroteBased on observation, interview, and record review, it was determined that for one (R90) out of one resident reviewed for respiratory care, the facility failed to ensure that R90 received oxygen per physician's order.
Inspectors wroteBased on record review and interview, it was determined that for one (R173) out of one resident reviewed for pain management, the facility failed to provide pain management according to professional standards of practice. R173 was not provided pain medication since before admission to the facility at 11:00 AM until pain medication administration at 7:08 PM, an estimated eight hours. The facility's failure to administer pain medication caused R173 to experience unnecessary pain related to a recent amputation.
Inspectors wroteBased 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 two out of five (E25 and E26) sampled employees.
Inspectors wroteBased on record review and interview, it was determined that for one (R107) out of five residents reviewed for unnecessary medications, the facility failed to act on a pharmacy medication review recommendation for R107.
Inspectors wroteBased on observation, interview, and record review, it was determined that for one (R109) out of two residents reviewed for dental care, the facility failed to provide routine dental services to meet R109's needs.
Inspectors wroteBased on observation and interview, it was determined that for one (R126) out of four sampled residents reviewed for food, the facility failed to provide food that accommodated R126's allergies.
Inspectors wroteBased on interview, review of the facility assessment and an identified deficient practice scoped as an Immediate Jeopardy during the survey, it was determined that the facility failed to conduct a quality assurance and performance improvement activity in response to R322's significant medication error and adverse event on 7/6/24. The facility failed to analyze the cause(s), implement preventive actions and mechanisms that included feedback and learning throughout the facility.
Inspectors wroteBased on record review and interview, it was determined that for one (R21) out of five residents reviewed for immunizations, the facility failed to provide evidence that the Pneumococcal vaccine was offered or declined. Additionally, for one (R26) out of the same five residents reviewed for immunizations, the facility failed to provide evidence that the influenza vaccine was offered or declined.
Inspectors wroteBased on interview and record review it was determined that one (R26) out of five residents sampled for COVID-19 Immunization the facility failed to provide evidence that R26 had consented or declined to be given the COVID-19 vaccine.
Inspectors wroteBased on interview and review of facility documentation it was determined that for three (E14, E27 and E28) out of nine employees sampled the facility failed to provide abuse, neglect, exploitation, and dementia training at least annually. In addition, E21 did not have dementia training.
Inspectors wroteBased on interview and review of the facility's policy and procedure, it was determined that the facility failed to ensure mandatory effective communication training was completed for all direct care staff.
Inspectors wroteBased on interview, record review and review of facility documentation as indicated, it was determined that for one (R324) out of four residents reviewed for falls, the facility failed to inform R324's representative/POA (Power of Attorney) of a fall.
Inspectors wroteBased on interview, record review and review of facility documentation as indicated, it was determined that for one (R340) out of two residents reviewed for death, the facility failed to consult with R340's physician of her repeated refusals of two medications.
Inspectors wroteBased on record review and interview, it was determined that for two (R323 and R423) out of two residents reviewed for grievances, the facility failed to ensure that concerns for missing dentures and a fall were resolved in a timely manner.
Inspectors wroteBased on record review and interview, it was determined that for one (R109) out of three residents reviewed for abuse, the facility failed to ensure that R109 was protected from verbal and emotional abuse when a staff member accused him of stealing chips that were left over from a staff party.
Inspectors wroteBased on observation, interview, record review and review of facility documentation as indicated, it was determined that for two (R94 and R31) out of seven residents reviewed for activities of daily living (ADLs), the facility failed to ensure each dependent resident received the necessary services to maintain grooming and personal hygiene.
Inspectors wroteBased on observation and interview it was determined that for one (R129) out of two residents reviewed for pressure ulcers the facility failed to promote of healing of pressure ulcers when pressure ulcer prevention interventions were observed not in place.
Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure that medications were stored and labeled properly in one out of three medication carts reviewed. Finding's include: The facility policy on storage of medications, last updated August 2020 indicated, .When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 12/4/24 - 2:35 PM - During a medication storage review of the second floor the following observed inside the Heritage II medication cart: - Four opened bottles of oral liquid medications with no open date labeled. - One opened bottle of powdered oral medication with no open date labeled. 12/4/24 - E3 (LPN) immediately confirmed the findings.
Inspectors wroteBased on record review and interview, it was determined that for one (R119) out of fifty-four residents sampled in the survey, the facility did not maintain accurate medical records.
Inspectors wroteBased on interview and review of facility documentation, it was determined that for three (E14, E26 and E27) out of five sampled CNA's (Certified Nursing Assistants) reviewed the facility failed to ensure that these employees had the mandatory twelve hours of annual in-service training.
Inspectors wrote2. The laundry room tour on 8/21/23 at 10:00 AM revealed the following: 8/21/23 at 10:00 AM - The laundry room back door of the soiled linen room was propped open and not kept closed. Finding was reviewed and confirmed by E24 (Director of Housekeeping) on 8/17/23 at approximately 11:15 AM.
Inspectors wrote4. The facility's policy and procedure entitled Fluid Management/Fluid Restriction, effective date 11/1/19, stated, The nursing staff will assess and monitor adherence to fluid management for patients placed on fluid restrictions. Procedure: Fluid Restrictions . 3. Determine amount of fluids with each meal, before bed time and with medication administration using guidelines in table . and consideration of patient preferences . 4. Monitor for signs of dehydration: . c. Abnormal serum sodium . levels . 5. Notify Physician and Responsible Party as indicated if non-adherence to fluid restriction status noted . 7. Document adherence/non-adherence to fluid restriction status, any signs of dehydration, any unusual findings and follow-up intervention including notification of physician/responsible party in the Progress Note. Document fluid intake. R182's clinical record revealed: [...]
Inspectors wroteBased on interview and record review it was determined that for three (R173, R174 and R410) out of three residents reviewed for accidents the facility failed to ensure the resident's environment was free from accident hazards and/or adequate supervision was provided to prevent accidents. F173, had a fall from bed while reaching for a urinal left out of reach resulting in harm, subsequently sustaining two broken areas in the spine. For R174, the facility failed to provide adequate supervision and assistance with toileting resulting in harm when the resident fell and sustained a broken hip. For R410, the facility failed to assess resident falls and implement measures to prevent falls.
Inspectors wroteBased on interview and record review it was determined that for two (R167 and R508) out of eight residents reviewed for pain management the facility failed to ensure the treatment and care for was in accordance with professional standards of practice related to pain management. For R167, pain was not managed resulting in the resident being sent to the emergency room for uncontrollable pain to the left hip causing harm to the resident. For R508, the facility failed to provide pain medication to a resident in pain in a timely manner. Additionally, R508 had a recommendation for adding another dose of morphine after being seen in a palliative care center and the facility failed to acknowledge and implement for a week.
Inspectors wroteBased on observation and interview it was determined that the facility failed to implement a grievance policy and postings that included a process for residents and families to file anonymous grievances and to identify the grievance official.
Inspectors wrote7. R125's clinical record revealed: 6/13/23 - R125 was admitted to the facility with diagnoses including deep vein thrombosis (blood clot in the right lower extremity). 6/13/23 - R125's physicians' orders included lovenox 40 mg/0.4 ml (Enoxaparin Sodium) injection daily for deep vein thrombosis. 8/21/23 - There was no evidence in R125's medical records that a pharmacist's review was conducted for the admission medications orders and for July 2023. 8/22/23 10:30 AM - The absence of the pharmacist's reviews were confirmed with E2 (Regional Clinical Director). 8. A policy and procedure titled, Medication Regimen Review Policy # 11.1 dated 8/2020 documented .D. The prescriber is notified as needed. Further review of the policy had not indicated a detailed time frame for when the facility will respond to the Consultant Pharmacist recommendation. [...]
Inspectors wroteBased on observation and interview, it was determined that the facility failed to provide and store food in accordance with professional standards for food service safety.
Inspectors wroteBased on observations, interviews and survey investigative findings, it was determined that the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently during a COVID-19 outbreak where the facility failed to implement their infection control program, despite having a COVID-19 policy and procedure and access to the current guidance from the Centers of Disease Control and Prevention (CDC).
Inspectors wroteBased on observation and interview, the facility failed to ensure that the QAA committee measured the success of actions, track performance and regularly review, analyze, and act on data collected.
Inspectors wroteBased on record review it was determined that for five (E40, E66, E87, E88 and E89) out of five employees sampled the facility failed to provide abuse, neglect, exploitation, and dementia training at least annually for E87 and E88.
Inspectors wroteBased on record review it was determined that for five (E40, E66, E87, E88 and E89) out of five employees sampled the facility failed to provide QAPI (Quality Assurance Process Improvement) training at least annually.
Inspectors wrote3. Review of R26's clinical record revealed: 6/29/23 - R26 was admitted to the facility with a diagnosis of right fifth toe amputation and a right foot infection, vascular dementia, and bipolar disorder. 8/22/23 11:00 AM - Review of R26's clinical record lacked information for an advanced directive. 8/22/23 11:44 AM - During an interview R26 said, they didn't talk to me about anything, and no one talked to me about what my wishes were. 8/22/23 12:15 PM - Review of R26's Discharge Planning admission Assessment, dated 7/12/23, documented that R26 does not have an advanced directive. Additionally, the reviewed documentation lacked evidence that an advanced directive had been offered and or that R26 did not want an advanced directive. [...]
Inspectors wrote8. The following was reviewed in R173's clinical record: 4/11/22 - R173 was admitted to the facility with dementia. 4/11/22 - R173 was care planned for alteration in musculoskeletal status with interventions including but not limited to: monitoring for risk of falls, educating the resident, family/caregivers on safety measures to reduce risk of falls (9/18/22), bed in low position (4/12/22); educate resident on calling for help prior to reaching for nightstand (2/6/23); have commonly used articles within easy reach (4/12/22), educate resident on use of reacher and calling for help (2/2/23); and encourage to transfer and change positions slowly (4/12/22). 4/24/22 - Per the facility's investigation report at approximately 4:57 AM, the resident was found lying on the floor and the socks were off on the floor near R173's feet. [...]
Inspectors wrote6. Review of R 113's clinical record revealed: 7/8/23 - R113 was admitted to the facility with multiple diagnoses including a stroke, that resulted in loss of movement to one sided of his body. 7/14/23 - R113's admission Minimum Data Set (MDS) revealed that R113 was cognitively intact. For Activities of Daily Living, the MDS revealed that R113 needed one person assistance for toilet use and that R113's always lacked control of bowel and bladder (incontinence). 9/1/23 - A review of a 9/1/23 8:00 AM facility incident report for R113 revealed that R113 stated to facility staff that he had not had toileting care throughout the previous night (8/31/23) until 9/1/23 at 6:00 AM. 9/1/23 11:45 AM - During an interview with R113, it was confirmed that care was not provided until 6:00 AM and R113 sat in his urine. [...]
Inspectors wroteBased on interviews and reviews of clinical records, it was determined that for nine (R92, R108, R110, R113, R147, R411, R606, R167 and R508) out of 15 residents reviewed for ADLs (including toileting/showers), the facility failed to have sufficient staff to provide basic nursing care services in accordance with the residents' care plan and to meet each resident's needs.
Inspectors wroteBased on record review and interviews, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing services for two (R143 and R172) out of seventy-six (76) residents in the investigative sample to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment.
Inspectors wroteBased on interview and record review of facility documentation, it was determined that the facility failed to ensure that a performance review was completed at least every 12 months for five (E78, E79, E80, E81 and E82) out of six sampled employees.
Inspectors wroteBased on observation of and two out of two test tray results, it was determined that the facility failed to provide food at a palatable taste.
Inspectors wroteBased on interview and review of related documentation, it was determined that the facility failed to provide evidence of a written transfer agreement with one or more hospitals approved for participation under the Medicare and Medicaid programs.
Inspectors wroteBased on clinical record review and interview, it was determined that for four (R177, R178, R143 and 121) out of four residents reviewed for hospice, the facility failed to ensure a communication process was in place that hospice records were complete and readily accessible. In addition, the facility failed to ensure coordination and collaboration with hospice when R178 had an unplanned transfer and admission to the hospital on [DATE]. In addition for R121 there was not an agreement in place for that provider.
Inspectors wroteBased on a review of facility documentation, it was determined that the facility failed to conduct quarterly Quality Assurance Performance Improvement (QAPI) meetings and to maintain a QAPI committee of the required members.
Inspectors wroteBased on interview and record review it was determined that for one (R162) out of 15 residents reviewed for abuse, the facility failed to ensure R162 was free from verbal abuse and physical abuse when a nurse called R162 a dumbass and pulled a gown over his head.
Inspectors wroteBased on interview and record review it was determined that for one (R162) out of 15 reviewed for abuse the facility failed to report an allegation of abuse within the required time frames.
Inspectors wroteBased on interview, record review and review of other facility documentation as indicated, it was determined that for one (R170) out of fifteen residents reviewed for abuse, the facility failed to investigate, prevent, and/or correct alleged abuse violations. For R170, the facility failed to maintain documentation that appropriate corrective action was taken as a result of R170's alleged violation of abuse.
Inspectors wroteBased on record review and interview, it was determined that for one (R178) out of six residents reviewed for transfer/hospitalization, the facility failed to provide written notice to R178's resident representative regarding the resident's hospital transfer.
Inspectors wrote2. Review of R92's clinical record revealed: 3/31/23 - R92 was admitted to the facility with a broken right leg. 7/5/23 - R92's quarterly MDS assessment documented that R92 had a hip fracture (and not a broken leg) and did not have any surgical wounds. 8/22/23 8:06 AM - A skin and wound note documented: The patient has a surgical wound. Presence of other specified functional implants (external fixator). 8/22/23 9:41 AM - During an interview, E64 (MDS Coordinator) confirmed R92's 7/5/23 quarterly MDS assessment did not reflect that R92 had a broken leg and surgical wounds. Based on record review and interview, it was determined that for four (R92, R103, R160, and R256) out of 76 sampled residents the facility failed to ensure the MDS assessment accurately reflected the residents status.
Inspectors wroteBased on interview and record review, it was determined that for one (R75) out of four residents reviewed for PASARR, the facility failed ensure that a referral for a PASARR (Preadmission Screening and Resident Review) screening was completed following a significant change.
Inspectors wroteBased on interview and record review, it was determined that for two (R125 and R139) out of four residents sampled for PASARR review, the facility failed to provide evidence that a Delaware State PASARR was obtained prior to admission.
Inspectors wroteBased on interview and record review, it was determined that for two (R160 and R182) out of thirteen residents sampled for quality of care, the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care. For R182, the facility failed to develop and implement a care plan to address her skin integrity issues upon admission. For R160 the baseline care plan did not include epilepsy including seizure prevention interventions.
Inspectors wroteBased on record review and interview it was determined that for two (R163 and R172) out of seventy-six residents reviewed for investigations, the facility failed to develop and implement comprehensive resident centered care plans for identified care areas.
Inspectors wroteBased on observation, interview, and record review it was determined that for two (R126 and R139) out of two residents reviewed for bowel and bladder management, the facility failed to ensure that appropriate assessments, treatments, and services were rendered to achieve normal bowel and bladder continence to the extent possible.
Inspectors wrote2. Review of R75's clinical records revealed: 7/6/23 - R75 was admitted to the facility with diagnoses including dementia. 7/12/23 - R75's admission MDS assessment revealed that R75 was cognitively impaired and required supervision of one staff member assist with eating. R75 was holding food in mouth/cheek or residual food in mouth after meals. 7/10/23 - R75 had a care plan for an actual or potential nutritional problem related to dementia .with interventions including but not limited to: encourage to eat .record meal % intake .therapeutic diet as ordered . 8/18/23 1:27 PM - A nursing progress note documented that R75 was rescheduled for an endocrinologist appointment for Monday (8/21/23) at 1:30 PM at (hospital). [...]
Inspectors wroteBased on observation, interview and record review. it was determined that for one (R132) out of four sampled residents reviewed for respiratory care, the facility failed to ensure that R132 was provided respiratory care consistent with his physician order and comprehensive person-centered care plan.
Inspectors wroteBased on record review, interview, and review of other facility documentation, it was determined that for one (R49) out of two residents reviewed for dialysis services, the facility failed to review a medication order conveyed by R49's dialysis communication form upon return to facility after dialysis. In addition, the facility failed to clarify the recommended order to ascertain whether the dosage/frequency of the medication and whether it was to be administered at the facility, or to be administered at dialysis. The facility also lacked evidence that six out of eight opportunities R49's post dialysis communication documentation sheets were reviewed by the facility for any pertinent information or recommendations.
Inspectors wroteBased on interviews and reviews of clinical records, the facility failed to ensure that for one (R172) out of seventy-six residents in the investigative sample that were reviewed for medical care supervised by a physician, the facility failed to ensure that one of R172's medication orders contained accurate medication administration instructions.
Inspectors wroteBased on record review and interview it was determined that for four (R25, R26, R59 and R75) out of seven residents reviewed for unnecessary medication review the facility failed to ensure residents were free from unnecessary psychotropic medication use. For R25 the facility failed to ensure an ordered psychotropic medication had the correct indication for use. For R75, the facility failed to ensure R75's medication regimen was free from unnecessary medications when he was prescribed and started using Trazodone Q 6 hours PRN for agitation. In addition, for R26, R59, and R75 the facility failed to initiate AIMS assessment for the use of anti-psychotic medication.
Inspectors wroteBased on observation and interview it was determined that for two (2) out of three medication rooms the facility failed to ensure that medications that required refrigeration were stored under the proper temperatures. Additionally, in one (1) out of three medication rooms the facility failed to securely store a Schedule II controlled drug in a locked and permanently attached compartment.
Inspectors wroteBased on interview and record review, it was determined that for one (R182) out of ten residents reviewed for change of condition, the facility failed to obtain laboratory services.
Inspectors wroteBased on interview and record review, it was determined that for one (R182) out of ten residents reviewed for a change of condition, the facility failed to ensure that her medical record was complete.
Inspectors wroteBased on interview and record review it was determined that one (R136) out of five residents sampled for COVID-19 Immunization the facility failed to provide R136 education for COVID-19. In addition, R136's clinical record lacked evidence that R136 had consented or declined to be given the COVID-19 vaccination.
Inspectors wroteBased on observation and interview it was determined that the facility failed to ensure that the State survey results were available for residents to read.
Inspectors wroteBased on record review and interview it was determined that the facility policy for abuse failed to include written procedures that ensure that all residents are protected from physical and psychosocial harm during and after the investigation.
Inspectors wroteBased on interview and review of other pertinent documentation it was determined that the facility failed to maintain posted daily nurse staffing data for a minimum of 18 months.
Inspectors wroteBased on observation, interview and record review it was determined that the facility failed to ensure residents were served meals that followed the menu displayed. The first floor [NAME] unit [week 4], second floor unit [week 1 and 4] and front lobby [week 3] displayed menu's that didn't reflect the current menu selection of week 2. Additionally for R104 the facility failed to serve the meal listed on the menu.
Inspectors wroteBased on record review and interview, it was determined that for one (R35) out of three residents reviewed for notification of changes, the facility failed to notify R35's emergency contact when R35 fell and was transferred to the hospital.
Inspectors wroteBased on observation, interview and record review, it was determined that for one (R103) out of one resident reviewed for activities the facility failed to implement resident centered activities programs that incorporates the resident's interests, hobbies, and cultural preferences. R103 was Mandarin speaking.
Inspectors wroteBased on record review and interviews, it was determined that for one (R160) out of three reviewed for hospitalization the facility failed to ensure that R160 was free of significant medication errors. For R160 the facility failed to administer a seizure medication for three days and anti-coagulant therapy.
Inspectors wroteBased on observations and interviews, it was determined that the facility failed to provide and store food in accordance with professional standards for food service safety.
Inspectors wroteBased on observation and interview it was determined that the facility failed to ensure a call bell was in reach for one (R55) out of 89 residents reviewed.
Inspectors wroteBased on interviews and record review, it was determined that for two residents (R12 and R16) out of 39 sampled residents, the facility failed to review and revise the comprehensive person-centered care plan.
Inspectors wroteBased on record review and interview, it was determined that the facility failed to monitor if the fluid restriction was maintained for one (R388) out of four residents reviewed for hydration.
Inspectors wroteBased on observation, interview, and record review, it was determined that for one (R16) out of six (6) residents sampled for unnecessary medication review, the facility failed to properly label and store the medication.
Inspectors wroteBased on observation, interview and record review it was determined that for one (R53) out of three residents reviewed for food preferences, the facility failed to accommodate R53's food preferences or choices.
Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to provide special adaptive equipment, built-up grip utensils for one (R16) resident during a random meal observation.
Inspectors wrote2. Observation of R40's pressure ulcer (PU) wound treatment and review of clinical records revealed the following: 1/25/22 - R40 was admitted to the facility with multiple pressure ulcers including a PU of the sacrum. a. 5/5/22 - Review of the physician's order for the sacrum PU wound treatment included to apply gentamycin, an antibiotic ointment. 5/6/22 11:19 AM - An observation of the daily sacrum PU wound treatment performed by E4 (RN UM) was conducted and no application of gentamycin was observed. 5/6/22 11:50 PM - A post wound observation interview with E4 (RN UM) revealed that she was part of the facility's wound team and during the most recent weekly wound team rounds which occurred on 5/4/22, E4 recalled that the gentamycin ointment was to be discontinued. [...]
7 fire safety citations on file: 1 on September 10, 2024, 2 on September 25, 2023, 4 on May 12, 2022.
| Date | Penalty | Amount or length |
|---|---|---|
| September 10, 2024 | Fine | $221,208 |
| September 10, 2024 | Payment Denial | 64 days from October 17, 2024 |
| September 25, 2023 | Fine | $263,388 |
| September 25, 2023 | Payment Denial | 114 days from November 14, 2023 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Delaware | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.88 | 4.35 | 3.86 |
| Registered nurses | 0.53 | 0.97 | 0.69 |
| All nursing staff on weekends | 3.56 | 3.89 | 3.42 |
| Nurse aides | 2.23 | ||
| Licensed practical nurses | 1.12 | ||
| Nursing staff turnover (share who left in a year) | 45.3% | 41.3% | 45.8% |
| Registered nurse turnover | 34.8% | 41.2% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.87 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.02 on weekdays and 3.56 on weekends, 11% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.2% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.85 in April to June 2025 to 3.88 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.88 | 0.53 | 4.02 | 3.56 | 0.2% | 0 of 90 | 171 |
| Oct to Dec 2025 | 3.93 | 0.55 | 4.07 | 3.58 | 1.3% | 0 of 92 | 166 |
| Jul to Sep 2025 | 3.79 | 0.58 | 3.98 | 3.32 | 4.2% | 0 of 92 | 157 |
| Apr to Jun 2025 | 3.85 | 0.67 | 4.01 | 3.44 | 6.8% | 0 of 91 | 142 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Delaware, Jan to Mar 2026 | 4.05 | 0.79 | 4.21 | 3.67 | 5.7% | 0% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Delaware, all employers | |||
| CNAs (nursing assistants) | $20.21 | $18.51 to $21.74 | 5,530 |
| LPNs and LVNs | $33.03 | $30.97 to $36.07 | 2,240 |
| Registered nurses | $47.85 | $41.30 to $53.71 | 14,290 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Delaware | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 10.8 | 12.7 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.3 | 0.5 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.4 | 2.1 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 1.5 | 3.2 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.8 | 1.0 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 13.6 | 13.6 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 2.6 | 3.5 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 13.3 | 10.7 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 18.8 | 23.4 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 7.2 | 11.6 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.4 | 1.8 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.5 | 1.4 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Pike Creek Nursing & Rehabilitation Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (61.3% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
61.3% this home
Better than the national rate
US median of homes 51.5% · Delaware: 17 better, 1 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 327 eligible stays.
10.5% this home
No different from the national rate
US median of homes 10.7% · Delaware: 1 better, 0 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 337 eligible stays.
8.0% this home
No different from the national rate
US median of homes 7.1% · Delaware: 0 better, 0 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 170 eligible stays.
73.1% this home
Median of homes: Delaware59.6% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 93 residents counted.
0.0% this home
Median of homes: Delaware0.8% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 134 residents counted.
0.7% this home
Median of homes: Delaware2.4% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 134 residents counted.
98.4% this home
Median of homes: Delaware98.7% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 62 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: PIKE CREEK SNF OPERATOR LLC. CMS links this home to Lifeworks Rehab, a group of 64 nursing homes averaging 2.1 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Pike Creek SNF Operator Holdings LLC | 5% or greater direct ownership interest | Organization | 100% | 08/01/2023 |
| Glen Holdco LLC | 5% or greater indirect ownership interest | Organization | 08/01/2023 | |
| Highland De Holdings LLC | 5% or greater indirect ownership interest | Organization | 08/01/2023 | |
| J & R Family Investments, LLC | 5% or greater indirect ownership interest | Organization | 08/01/2023 | |
| Jk 2022 Family Trust | 5% or greater indirect ownership interest | Organization | 08/01/2023 | |
| Landau Family Investment Trust | 5% or greater indirect ownership interest | Organization | 08/01/2023 | |
| Mimi Holdco LLC | 5% or greater indirect ownership interest | Organization | 08/01/2023 | |
| Panther De Partners LLC | 5% or greater indirect ownership interest | Organization | 08/01/2023 | |
| Vh Wpc SNF Operations Holdings LLC | 5% or greater indirect ownership interest | Organization | 08/01/2023 | |
| Wpc SNF Operations Holdings LLC | 5% or greater indirect ownership interest | Organization | 08/01/2023 | |
| White, Rebecca | W-2 managing employee | Individual | 08/01/2023 | |
| Rajchenbach, Moshe | Corporate officer | Individual | 08/01/2023 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
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