Based on observations, interviews and reviews of clinical records and other facility documentation, it was determined that the facility failed to ensure there were sufficient nursing staff to administer critical medications to meet the needs of the residents during the 7:00 AM to 3:00 PM shift on Friday, 7/21/23. For three residents (R22, R51 and R630) on the Dover Unit that were ordered Humalog insulin to be administered with breakfast (scheduled at 7:35 AM), revealed the following: - R22 was never administered insulin with breakfast. - R51 was administered insulin at 10:48 AM and 10:50 AM, approximately 3.5 hours later. - R630 was administered insulin at 9:56 AM and 9:57 AM, approximately 2.5 hours later. …
F725 citations in Delaware
Sufficient nursing staff · Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Delaware cites F725 less often than its own record predicts
0.28 times the national share — cited less often here than elsewhere.
Of every deficiency written in Delaware in 2025, this is the portion that was F725.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Delaware surveyors wrote
F725 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 observations, interviews, record reviews, and facility policy review, the facility failed to ensure call lights were answered timely for one of 38 sample residents (Resident (R) 44) reviewed for staffing. This failure had the potential to put the residents at risk. Findings include: Review of R44's Admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admitted [DATE]. Review of R44's admission Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 11/20/24, revealed R44 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. …
The short window
Recent years
| Year | Share of Delaware citations | vs expected |
|---|---|---|
| 2023 | 0.53% | 0.66× |
| 2024 | 0.35% | 0.44× |
| 2025 | 0.21% | 0.28× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Delaware surveyors cite →
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