Based on interview, record review and identified deficiencies during the survey, it was determined that the facility's QAPI program failed to effectively address ongoing issues that impact quality of care with respect to staff to resident abuse, repeated medication errors by nursing staff and the continued lack of availability of medications from the pharmacy for multiple residents. Findings include: 3/25/25 1:08 PM - During a combined interview with E1 (CEO/LNHA) and E2 (DON), E1 stated that the QAPI Committee discusses all medication errors in their meetings. E1 mentioned that the 10/3/24 medication error incident involving four residents was reviewed and staff nurses were educated in November 2024. The Surveyor reviewed that there were additional medication errors on 1/3/25 and 2/11/25. …
F867 citations in Delaware
QAPI improvement activities · Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Delaware cites F867 less often than its own record predicts
0.65 times the national share — cited less often here than elsewhere.
Of every deficiency written in Delaware in 2025, this is the portion that was F867.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Delaware surveyors wrote
F867 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 review of facility documentation, review of cited deficiencies from the facility's annual survey of 7/14/23 and staff interview, it was determined that the facility's Quality Assurance and Performance Improvement (QAPI) program failed to correct previously cited deficiencies. Findings include: 7/11/24 - A review of the facilities undated policy titled, Medication Regimen Review, lacked information regarding the time frames for a pharmacist response, urgent and non-urgent medication recommendations, or a time frame for a facility response to recommendations. 7/11/24 - A review of the 2567 from Annual and Complaint survey dated 7/14/23 revealed a previous deficiency cited for the facilities MRR policy and lack of time frames for response times. …
The short window
Recent years
| Year | Share of Delaware citations | vs expected |
|---|---|---|
| 2023 | 0.79% | 1.36× |
| 2024 | 0.35% | 0.78× |
| 2025 | 0.21% | 0.65× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Delaware surveyors cite →
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