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Cadbury At Lewes

Details

Type of Ownership Non profit - Other
Participates in Medicare? Yes
Participates in Medicaid? Yes
Certified Beds 40
Continuing Care? No
Resident Council? Yes
Family Council? No
Multi-Home Chain? No
Located in a Hospital? No
Special Focus Facility? No

View:    Health Inspections  |  Quality Measures  |  Staffing  |  Fire Inspections

Health Inspections  

Most Recent Inspection: 06/15/2011

Date of last standard health inspection: 06/15/2011
Quality Indicator Survey No
Dates of Complaint Investigations: 04/01/2011 - 03/31/2012
Total number of Health Deficiencies for this nursing home: 0
Average number of Health Deficiencies in DE: 7
Average number of Health Deficiencies in US: 3
Range of Health Deficiencies in DE: 0 - 15

Inspection, 02/06/2010

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Choose a doctor to serve as the medical director to create resident care policies and coordinate medical care in the facility. 02/06/2010 01/08/2001 2 Few
Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 02/06/2010 01/08/2001 2 Some
Nutrition and Dietary Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Store, cook, and serve food in a safe and clean way. 02/06/2010 01/08/2001 2 Few
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. 02/06/2010 01/08/2001 2 Few
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure services provided by the nursing facility meet professional standards of quality. 02/06/2010 01/08/2001 2 Few
Provide necessary care and services to maintain or improve the highest well being of each resident. 02/06/2010 02/05/2001 3 Few
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. 02/06/2010 02/05/2001 2 Few
Develop policies and procedures for influenza and pneumococcal immunizations. 02/06/2010 01/08/2001 1 Many
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. 02/06/2010 01/08/2001 2 Some
Allow residents the right to participate in the planning or revision of care and treatment. 02/06/2010 01/08/2001 2 Few
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Give residents a notice of rights, rules, services and charges. 02/06/2010 01/08/2001 1 Some
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. 02/06/2010 01/08/2001 2 Few

Inspection, 01/00/2010

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Keep accurate, complete and organized clinical records on each resident that meet professional standards. 01/00/2010 01/05/2012 2 Some
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. 01/00/2010 01/05/2012 2 Many
Keep accurate 01/00/2010 01/05/2012 Some complete and organized clinical records on each re
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly 01/00/2010 01/05/2012 Many and develop corrective plans of action.
Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 01/00/2010 01/05/2012 2 Few
Have a program that investigates, controls and keeps infection from spreading. 01/00/2010 01/05/2012 2 Some
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 01/00/2010 01/05/2012 2 Few
Have a program that investigates 01/00/2010 01/05/2012 Some controls and keeps infection from spreading.
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. 01/00/2010 01/05/2012 2 Some
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. 01/00/2010 01/05/2012 2 Few
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. 01/00/2010 01/05/2012 2 Some
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. 01/00/2010 01/05/2012 2 Some
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. 01/00/2010 01/05/2012 2 Few
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. 01/00/2010 01/05/2012 2 Some
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide activities to meet the interests and needs of each resident. 01/00/2010 01/05/2012 2 Few
Provide necessary care and services to maintain or improve the highest well being of each resident. 01/00/2010 01/05/2012 2 Few
Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. 01/00/2010 01/05/2012 2 Few
Ensure residents maintain acceptable nutritional status. 01/00/2010 01/05/2012 2 Few
Provide activities to meet the interests and needs of each resident. 01/00/2010 01/05/2012 2 Few
Provide necessary care and services to maintain or improve the highest well being of each resident. 01/00/2010 01/05/2012 2 Few
Ensure that each resident who enters the nursing home without a catheter is not given a catheter 01/00/2010 01/05/2012 and that incontinent patients receive proper servi unless medically necessary
Ensure residents maintain acceptable nutritional status. 01/00/2010 01/05/2012 2 Few
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. 01/00/2010 01/05/2012 2 Some
Allow residents the right to participate in the planning or revision of care and treatment. 01/00/2010 01/05/2012 2 Few
Develop a complete care plan that meets all the resident's needs 01/00/2010 01/05/2012 Some with timetables and actions that can be measured.
Allow residents the right to participate in the planning or revision of care and treatment. 01/00/2010 01/05/2012 2 Few
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. 01/00/2010 01/05/2012 2 Few
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. 01/00/2010 01/05/2012 2 Few
Reasonably accommodate the needs and preferences of each resident. 01/00/2010 01/05/2012 2 Few
Immediately tell the resident 01/00/2010 01/05/2012 and a family member of situations (injury/decline/ the resident's doctor
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. 01/00/2010 01/05/2012 2 Few
Reasonably accommodate the needs and preferences of each resident. 01/00/2010 01/05/2012 2 Few

Inspection, 02/05/2006

Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 02/05/2006 02/06/2008 2 Few
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure services provided by the nursing facility meet professional standards of quality. 02/05/2006 02/06/2008 2 Few
Provide necessary care and services to maintain or improve the highest well being of each resident. 02/05/2006 02/06/2008 2 Few
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Develop a complete care plan that meets all the resident's needs 02/05/2006 02/06/2008 Few with timetables and actions that can be measured.

Inspection, 01/05/2006

Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Protect each resident from mistreatment, neglect and misappropriation of personal property. 01/05/2006 00/05/2009 2 Few
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. 01/05/2006 00/05/2009 2 Few
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. 01/05/2006 00/05/2009 2 Some
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. 01/05/2006 00/05/2009 2 Few
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. 01/05/2006 00/05/2009 2 Some
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. 01/05/2006 00/05/2009 2 Few
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. 01/05/2006 00/05/2009 2 Few

Inspection, 02/01/2005

Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. 02/01/2005 00/01/2008 2 Few

Nursing Home Staffing  

Information comes from data that the nursing home reports to its state agency. It contains the nursing home staffing hours for a two-week period prior to the time of the state inspection. CMS receives this data and converts it into the number of staff hours per resident per day.

National Average Average in DE Golden Living Center, Asheville
RN Staff Only1 N/A N/A 5 out of 5 stars
Total Number of Residents 86 87 35
Total, Licensed Nurse Staff Hours
per Resident per Day
16 hours 51 minutes 4 hours 28 minutes 2 hours 33 minutes
RN Hours
per Resident per Day
16 hours 3 minutes 3 hours 32 minutes 1 hour 10 minutes
LPN/LVN Hours
per Resident per Day
16 hours 17 minutes 3 hours 27 minutes 1 hour 22 minutes
CNA Hours
per Resident per Day
17 hours 46 minutes 5 hours 9 minutes 2 hours 48 minutes

1 The star rating a nursing home received for the information it provided about its Registered Nurse (RN) staffing. RNs have between 2 and 6 years of education.

Quality Measures  

Information comes from data that the nursing home reports to its state agency. It contains the nursing home staffing hours for a two-week period prior to the time of the state inspection. CMS receives this data and converts it into the number of staff hours per resident per day.

Long-Term Residents

Short-Term Residents

Fire Safety Inspections

Lists the fire safety requirements that the nursing home failed to meet. Fire safety results are not included in the nursing home's Overall Rating.

Most Recent Inspection: 06/20/2011

Automatic Sprinkler Systems in all required areas Yes
Date of last standard fire safety inspection: 06/20/2011
Dates of Complaint Investigations: 04/01/2011 - 03/31/2012
Total number of Fire Safety Deficiencies for this nursing home: 0
Average number of Fire Safety Deficiencies in DE: 0
Average number of Fire Safety Deficiencies in US: 2
Range of Fire Safety Deficiencies in DE: 0 - 0

Inspection, 00/04/2010

Emergency Plans and Fire Drills Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Record of quarterly fire drills for each shift under varying conditions. 00/04/2010 00/01/2011 2 Many

Inspection, 02/00/2006

Automatic Sprinkler Systems Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Automatic sprinkler systems that have been maintained in working order. 02/00/2006 00/07/2007 1 Some
Emergency Plans and Fire Drills Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Record of quarterly fire drills for each shift under varying conditions. 02/00/2006 00/07/2007 1 Some
Fire Alarm Systems Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
An approved installation, maintenance and testing program for fire alarm systems. 02/00/2006 00/07/2007 1 Some
Hazardous Area Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. 02/00/2006 00/07/2007 1 Some
 

17028 Cadbury Circle
Lewes, DE 19958

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