Based on interviews, record review, and policy review, the facility failed to ensure allegations of abuse were reported for one of three residents (Resident (R) 80) reviewed for abuse. The facility did not report to the State Agency alleged staff-to-resident abuse within the required time frame. Facility staff did not report R80's allegation of employee-to-resident abuse to the Administrator. This failure to report the allegation in a timely manner allowed the accused staff member to continue working in the facility with other residents. The Immediate Jeopardy began on 07/07/24, undetermined time between 12:00 PM and 3:00 PM. On 03/13/25 at 7:42 PM, the Administrator was notified of Immediate Jeopardy (IJ) Past Non-Compliance (PNC) in the area of Resident Abuse at F609. …
F609 citations in Delaware
Reporting alleged violations · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Delaware cites F609 more often than its own record predicts
1.65 times the share F609 takes of citations nationally.
Of every deficiency written in Delaware in 2025, this is the portion that was F609.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Delaware surveyors wrote
F609 findings written in Delaware, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on record review, interview, and policy review, the facility failed to ensure the results of an investigation involving an allegation of physical abuse were reported to the State Agency (SA) within five working days for one (Resident (R) 29) of seven abuse investigations reviewed from a sample of 42 residents. This deficient practice had the potential to delay SA oversight and intervention, which could affect the timely identification and correction of conditions that may place residents at risk for abuse. Findings include: Review of R29's electronic medical record (EMR) revealed the resident was originally admitted on [DATE] with a diagnosis of dementia. …
The short window
Recent years
| Year | Share of Delaware citations | vs expected |
|---|---|---|
| 2023 | 1.06% | 0.53× |
| 2024 | 3.68% | 1.61× |
| 2025 | 4.04% | 1.65× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Delaware surveyors cite →
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