Based on interviews, record review and review of other documentation as indicated, it was determined that for one (R23) out of three residents sampled for falls, the facility failed to ensure that readmission physician orders for two anti-seizure medications were accurately transcribed into the electronic health record for R23's immediate care of her seizure disorder. From 9/8/23 through 9/20/23, R23 did not receive 24 doses of Vimpat and was administered five (5) incorrect doses of Keppra. On 9/29/23, R23 had a seizure and fell during a therapy ambulation session and was transferred to the hospital, evaluated and treated with anti-seizure medication. Due to the facility's failure, an Immediate Jeopardy (IJ) was called at 3:20 PM on 10/26/23. The IJ was abated on 10/27/23 at 5:00 PM. …
F635 citations in Delaware
Resident Assessment and Care Planning Deficiencies
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Delaware cites F635 more often than its own record predicts
3.84 times the share F635 takes of citations nationally.
Of every deficiency written in Delaware in 2025, this is the portion that was F635.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Delaware surveyors wrote
F635 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 observation, interview, and record review, it was determined that for one (R150) out of one resident reviewed for admission orders, the facility failed to ensure wound treatment orders were entered. Findings include: Review of R150's clinical records revealed:9/16/25 - R150 was readmitted to the facility with diagnoses including diabetes mellitus, congestive heart failure, and epilepsy.9/19/25 - A readmission Wounds Assessment Report for R150 completed by P1 (NP) documented treatment orders for four wounds, noted as present on admission.9/22/25 3:30 PM - Review of R150's clinical record revealed no current orders for wound care.9/24/25 2:15 PM - During an interview, the Surveyor asked E14 (RN) if R150 had treatment orders for wound care since he was readmitted on [DATE]. …
The short window
Recent years
| Year | Share of Delaware citations | vs expected |
|---|---|---|
| 2023 | 0.79% | 12.39× |
| 2024 | 0.35% | 7.23× |
| 2025 | 0.21% | 3.84× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Delaware surveyors cite →
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