Based on record review and interview, it was determined that for one (R13) out of forty-five residents in the investigative sample, the facility failed to provide services that meet professional standards of quality by having Licensed Practical Nurses (LPN) complete post fall assessments. Findings include:Delaware State Board of Nursing - RN, LPN and NA/UAP Duties 2024 . RN . Post Fall Assessment & Documentation . updated 10/11/24.Review of R13's clinical record revealed:3/17/26 - R13 was admitted to the facility. 6/24/26 11:20 AM - A facility reported incident documented that R13 had a witnessed fall when standing up from wheelchair, lost balance, and fell making contact with a chair on the left side and shoulder while outside on the patio with activities. …
F658 citations in Delaware
Professional standards of care · Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Delaware cites F658 more often than its own record predicts
1.19 times the share F658 takes of citations nationally.
Of every deficiency written in Delaware in 2025, this is the portion that was F658.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Delaware surveyors wrote
F658 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.
The short window
Recent years
| Year | Share of Delaware citations | vs expected |
|---|---|---|
| 2023 | 0.26% | 0.17× |
| 2024 | 1.58% | 0.96× |
| 2025 | 2.13% | 1.19× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Delaware surveyors cite →
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