5 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Greenville, DE
4-star overall rating with 3-star inspections with $48,696 in total fines with 5 recent health deficiencies
4031 Kennett Pike, Greenville, DE
(302) 658-6200
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
49
Certified beds
Average residents
29
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1984-06-22
CMS approved date
Coverage
Medicare
Participation flags
Staffing
RN hours / resident day
2.08
Registered nurse staffing
LPN hours / resident day
1.18
Licensed practical nurse staffing
Aide hours / resident day
2.81
Nurse aide staffing
Weekend hours
5.54
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
31%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.8
1.1 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.4
0.9 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.7%
4.3 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.4%
2.6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.7% |
3.2%
2.5 pts worse
|
3.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 2.2% |
6.5%
4.3 pts better
|
11.4%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 1.1% |
5.6%
4.5 pts better
|
5.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.2% |
21.1%
1.1 pts worse
|
19.6%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 2.6% |
12.0%
9.4 pts better
|
16.7%
14.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.1% |
17.5%
2.6 pts worse
|
16.3%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.3% |
14.7%
10.6 pts worse
|
14.9%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 4.8% |
2.0%
2.8 pts worse
|
1.7%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.5% |
21.6%
5.9 pts worse
|
19.8%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
4.4%
4.4 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.5% |
83.5%
5 pts better
|
81.7%
6.8 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 24.1% |
11.2%
12.9 pts worse
|
12.0%
12.1 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
0.9%
0.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.5% |
83.1%
12.4 pts better
|
79.7%
15.8 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.2% |
21.5%
8.3 pts better
|
23.9%
10.7 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Nursing and Physician Services (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire Safety
Establish staff and initial training requirements.
Corrected 2021-12-31
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-01-31
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-31
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-01-31
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-01-31
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2025-01-31
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-18
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-01-18
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-01-18
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2024-01-18
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-01-18
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-01-18
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-01-18
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-01-18
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-01-18
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-12-31
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-12-31
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-12-31
Penalties and ownership
Fine · fine $48,696
Fine
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
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