Cycle 1
Health 2024-12-12 · Fire 2024-12-12
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Smyrna, DE
Delaware Hospital F/T Chronically Ill (Dhci)
5-star overall rating with 3-star inspections with $82,885 in total fines with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
100 Sunnyside Road, Smyrna, DE
(302) 223-1500
Overall
5 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
175
Certified beds
Average residents
72
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
2.64
Registered nurse staffing · state 1.03 · national 0.68
LPN hours / resident day
1.83
Licensed practical nurse staffing · state 1.01 · national 0.87
Aide hours / resident day
5.84
Nurse aide staffing · state 2.47 · national 2.35
Total nurse hours
10.30
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
4.47
RN + LPN hours · state 2.04 · national 1.54
Weekend hours
8.36
Weekend nurse staffing · state 4.04 · national 3.43
Weekend RN hours
1.61
Weekend registered nurse coverage · state 0.72 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.15 · national 0.07
Adjusted RN hours
2.74
CMS adjusted RN staffing hours
Adjusted total hours
10.73
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
37%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
80
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
88.06
Composite VBP score used to determine payment impact.
Payment multiplier
1.0271
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
7.61
Baseline 43.41% · Performance 32.57% · Measure score 7.61 · Achievement 7.61 · Improvement 5.34
Adjusted total nurse staffing
10
Baseline 10.80 hours · Performance 11.37 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 2 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · No data were submitted for this measure. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 377 |
| Staff flu vaccination coverage | 75.26% |
42%
33.3 pts better
|
Numerator 286 · Denominator 380 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.8
0.5 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 1.6 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.4
0.4 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 78.9% |
95.7%
16.8 pts worse
|
93.4%
14.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 83.6% · Q2 79.2% · Q3 74.3% · Q4 78.6% · 4Q avg 78.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.6% |
97.4%
1.2 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
3.2%
2.1 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 1.4% · Q4 1.4% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.5%
6.5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 1.4% |
5.6%
4.2 pts better
|
5.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 2.9% · Q4 0.0% · 4Q avg 1.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.8% |
21.1%
6.3 pts better
|
19.6%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 14.5% · Q3 14.5% · Q4 16.2% · 4Q avg 14.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.8% |
12.0%
2.8 pts worse
|
16.7%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 16.3% · Q3 13.7% · Q4 13.0% · 4Q avg 14.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 1.1% |
0.1%
1 pts worse
|
0.1%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 1.4% · Q4 0.0% · 4Q avg 1.1% |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.2% |
17.5%
11.3 pts better
|
16.3%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 10.1% · Q3 0.0% · Q4 8.9% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.6% |
14.7%
9.1 pts better
|
14.9%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 8.7% · Q3 4.5% · Q4 6.7% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.7%
0.2 pts worse
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.2% · Q3 1.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
2.0%
0.5 pts worse
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 1.4% · Q4 5.7% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.1% |
21.6%
9.5 pts better
|
19.8%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 18.2% · Q3 12.9% · Q4 9.4% · 4Q avg 12.1% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
4.4%
0.1 pts worse
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 4.0% · Q3 6.7% · Q4 6.1% · 4Q avg 4.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-10 · Fire 2024-01-10
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-02-22 · Fire 2022-02-22
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-12
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2025-01-31
F · Potential for more than minimal harm
2024-12-12
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-01-31
F · Potential for more than minimal harm
2024-12-12
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-12
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-12
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2025-01-31
Inspection history
Recent health citations
J · Immediate jeopardy
2025-10-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-11-17
J · Immediate jeopardy
2025-02-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-24
E · Potential for more than minimal harm
2022-02-22
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-04-05
D · Potential for more than minimal harm
2022-02-22
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2022-04-05
D · Potential for more than minimal harm
2022-02-22
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-04-05
D · Potential for more than minimal harm
2022-02-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-04-05
D · Potential for more than minimal harm
2022-02-22
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-04-05
D · Potential for more than minimal harm
2022-02-22
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-04-05
D · Potential for more than minimal harm
2022-02-22
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-04-05
D · Potential for more than minimal harm
2022-02-22
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-04-05
B · Minimal harm
2022-02-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-04-05
Penalties and ownership
What sits behind the stars
$65,540
2025-10-03
Fine
Fine · fine $65,540
Fine
$17,345
2025-02-24
Fine
Fine · fine $17,345
Fine
Ownership
Brogan, Barbara
Operational/Managerial Control · Individual
Kerkula, Barnabas
Operational/Managerial Control · Individual
Teeter, Tammy
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Evergreen Post Acute
Smyrna, DE
3-star overall rating with 2-star inspections with $94,156 in total fines with 23 recent health deficiencies
#2
Westminster Village Health
Dover, DE
4-star overall rating with 3-star inspections with $38,518 in total fines with 11 recent health deficiencies
#3
Complete Care At Silver Lake LLC
Dover, DE
3-star overall rating with 2-star inspections with $47,541 in total fines with 15 recent health deficiencies
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