Based on interview and documentation review, the facility failed to ensure the facility assessment described the staff competencies and skill sets that were necessary to provide the level and types of care needed for the resident population, specifically for CHF residents. Findings included: Cross refer to F684 Review of the Facility Assessment Silverside 2025 - 2026 revealed the following:-under Section B. Acuity-Disease, Condition, & Treatments, Heart Failure (CHF) diagnosis accounted for 30.5% of Admissions/Stays and were at a Very High Frequency Relative to Benchmark; and-under II. Staffing, Training, Services & Personnel, B. Acuity-Diseases, Conditions, & Treatments. Pulmonary. Staff Training/Competencies/Skill Sets Evaluated. Suctioning. …
F838 citations in Delaware
Facility assessment · Administration Deficiencies
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Delaware cites F838 less often than its own record predicts
0.84 times the national share — cited less often here than elsewhere.
Of every deficiency written in Delaware in 2025, this is the portion that was F838.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Delaware surveyors wrote
F838 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.
F838 Facility Assessment- Based on record review and interview, it was determined that the facility failed accurately update the Facility Assessment Tool, which was created May 2024, with the correct name of the Infection Preventionist. Findings include: 6/26/24 11:45 AM - Review of the Facility Assessment, which was dated May 2024, revealed on page 5 Infection Preventionist: [E3] (ADON). 6/27/24 1:56 PM - During an interview, E4 (Clinical Specialist) stated, That's not right. [E2] (DON) is the facility Infection Preventionist. [E3] cannot be the Infection preventionist; she is not certified. 7/1/24 10:46 AM - During an interview, E4(Clinical specialist) stated, Infection control is a group effort while we try to fill the role. …
The short window
Recent years
| Year | Share of Delaware citations | vs expected |
|---|---|---|
| 2024 | 0.35% | 1.80× |
| 2025 | 0.21% | 0.84× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Delaware surveyors cite →
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