Inspection Reports for Gilpin Hall Nursing Home
1101 Gilpin Avenue, DE, 19806
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 13, 2025, found the facility returned to substantial compliance with no deficiencies noted. Earlier inspections showed multiple deficiencies related to resident abuse prevention, medication management, infection control, supervision, and financial security. Complaint investigations substantiated incidents of resident-to-resident and staff-related abuse, including verbal and physical abuse, with corrective actions such as staff training and employee termination implemented. Enforcement actions such as fines or license suspensions were not listed in the available reports. The inspection history indicates some improvement over time, with the latest follow-up showing resolution of prior issues.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% better than Delaware average
Delaware average: 8.8 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
94 residents
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 13, 2025
Visit Reason
A desk review follow-up visit was conducted on December 1, 2025, for the annual and complaint visit ending August 29, 2025.
Findings
The facility was found to have returned to substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities as of October 13, 2025.
Report Facts
Date survey completed: Dec 1, 2025
Inspection Report
Annual Inspection
Census: 94
Deficiencies: 9
Date: Aug 29, 2025
Visit Reason
An unannounced annual, complaint, and emergency preparedness survey was conducted at the facility from August 25, 2025, through August 29, 2025.
Findings
The survey identified multiple deficiencies related to financial security, resident abuse policies, reporting of alleged violations, discharge processes, PASARR assessments, quality of care, drug regimen review, and medication storage. The facility failed to meet several regulatory requirements as evidenced by the cited deficiencies.
Deficiencies (9)
Facility failed to have a surety bond that covered the current balance in residents' trust accounts.
Facility failed to protect resident R81 from misappropriation of property related to missing medication.
Facility failed to develop and implement abuse policies that included required elements and training.
Facility failed to report alleged violations of abuse and injury within required timeframes.
Facility failed to notify Ombudsman timely regarding resident R96's discharge.
Facility failed to coordinate PASARR assessments for residents with significant changes.
Facility failed to ensure documentation of daily weights for resident R1.
Facility failed to conduct timely drug regimen reviews and communicate irregularities.
Facility failed to properly secure narcotics in medication room lockboxes.
Report Facts
Facility census: 94
Survey sample size: 24
Surety bond coverage: 30000
Surety bond amount: 20000
Trust account balance: 28733.79
Medication missing cash price: 1122.04
Audit compliance months: 3
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 6
Date: Oct 18, 2024
Visit Reason
A Recertification and Complaint Survey was conducted by Healthcare Management Solutions LLC on behalf of the State of Delaware, Department of Health and Social Services, Division of Health Care Quality from 10/14/24 to 10/18/24. The facility was found not to be in substantial compliance with 42 CFR 483 subpart B.
Complaint Details
The visit was complaint-related and included substantiated findings of abuse and neglect involving multiple residents. The facility failed to fully investigate and prevent incidents of physical and verbal abuse, and failed to protect residents from harm.
Findings
The survey identified multiple deficiencies including failure to notify resident representatives timely after incidents, failure to provide timely and adequate grievance resolution, failure to prevent and investigate abuse and neglect, failure to provide adequate pain management, failure to ensure infection control practices, and failure to ensure proper use of mechanical lifts and resident safety measures.
Deficiencies (6)
Failure to notify resident representative timely following a fall with injuries and failure to document notifications properly.
Failure to provide timely and adequate grievance resolution for residents.
Failure to ensure residents were free from abuse and neglect, including physical and verbal abuse by staff and other residents.
Failure to provide adequate pain management and timely assessment of injuries.
Failure to ensure infection prevention and control practices, including hand hygiene and cleaning procedures.
Failure to ensure proper use and competency of mechanical lifts and safe resident handling.
Report Facts
Survey Census: 94
Sample Size: 34
Supplemental Residents: 8
Number of residents reviewed for abuse: 7
Number of residents reviewed for pain management: 34
Number of residents reviewed for infection control: 34
Number of residents reviewed for mechanical lift use: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA7 | Certified Nursing Assistant | Named in abuse and neglect findings including verbal and physical abuse incidents |
| LPN1 | Licensed Practical Nurse | Named in incident report and wound care observations |
| DON | Director of Nursing | Named in multiple findings related to investigations, staff education, and policy enforcement |
| ADON | Assistant Director of Nursing | Named in investigation and interview related to abuse incidents |
| RN1 | Registered Nurse | Named in incident response and resident assessment |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 3
Date: Dec 14, 2023
Visit Reason
A Recertification and Complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Delaware Department of Health and Social Services, Division of Healthcare Quality, from December 11 through December 14, 2023, to assess compliance with 42 CFR 483 subpart B.
Complaint Details
The complaint investigation substantiated multiple incidents of resident-to-resident sexual and physical abuse, including verbal abuse by staff. The facility failed to ensure residents' safety and proper reporting to the State Agency. Staff training and behavior assessment tools were implemented as corrective actions. An employee (CNA5) was suspended and terminated following investigation of verbal abuse.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies included failure to ensure residents were free from abuse, neglect, and exploitation, medication administration errors, and infection control issues. Multiple incidents of resident-to-resident sexual abuse and physical abuse were documented, with root causes identified as incomplete resident assessments and inadequate staff training.
Deficiencies (3)
Failure to ensure one resident was free from sexual abuse by another resident and failure to protect a resident from verbal abuse by a Certified Nursing Assistant.
Failure to provide pharmaceutical services including accurate medication administration and record keeping.
Failure to establish and maintain an infection prevention and control program, including hand hygiene and linen handling.
Report Facts
Survey Census: 91
Sample Size: 36
Supplemental Residents: 0
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 5 | Certified Nursing Assistant | Named in verbal abuse finding and terminated after investigation |
| Joan Barna | Administrator | Signed the state survey report and involved in investigation |
Inspection Report
Follow-Up
Census: 85
Deficiencies: 1
Date: Aug 30, 2022
Visit Reason
An unannounced follow-up survey was conducted from August 26, 2022 through August 30, 2022, following a complaint survey ending July 28, 2022.
Complaint Details
This was a follow-up survey to a complaint survey ending July 28, 2022. The complaint was substantiated as neglect related to staff using personal cell phones and failing to supervise resident R1, resulting in falls.
Findings
The facility failed to ensure adequate supervision to prevent accidents, specifically two falls involving resident R1, due to staff neglect and improper use of personal cell phones during duty. The facility implemented a Safety Program with increased supervision and monitoring to address these issues.
Deficiencies (1)
Failure to ensure resident environment free of accident hazards and provide adequate supervision and assistance devices to prevent accidents, resulting in two falls of resident R1.
Report Facts
Facility census: 85
Survey sample size: 3
Date range of survey: August 26, 2022 through August 30, 2022
Number of falls documented for resident R1: 2
Temperature: 98.2
Respirations: 18
Vital signs - blood pressure: 116
Vital signs - pulse: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E7 | Safety Program Certified Nursing Assistant (SP CNA) | Named in neglect finding for using personal cell phone during duty and failing to supervise resident R1, resulting in falls and termination. |
| E8 | Licensed Practical Nurse (LPN) | Witnessed second fall of resident R1 and reported incident. |
| E3 | Certified Nursing Assistant (CNA) | Interviewed regarding toileting resident R1 and supervision. |
| E11 | Safety Program Certified Nursing Assistant (SP CNA) | Confirmed assignment to watch resident R1 and others during Safety Program. |
| E9 | Licensed Practical Nurse (LPN) | Interviewed about first fall of resident R1 and assistance provided. |
| E10 | Physical Therapist (PT) | Provided therapy notes and Safety Program input regarding resident R1. |
| Director of Nursing | Provided nursing staff in-service on facility policy of cell phone/personal device usage and reviewed Safety Program procedures. |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 1
Date: Jul 28, 2022
Visit Reason
An unannounced complaint survey was conducted at the facility from July 18, 2022 through July 28, 2022 based on observations, interviews, and review of residents' clinical records and other facility documentation.
Complaint Details
The complaint investigation found that for three residents (R1, R2, and R4), the facility failed to provide adequate supervision to prevent accidents. Resident R1 suffered a severe adverse outcome leading to death. Resident R2 sustained harm from a fall, and Resident R4 was harmed after being left unattended and falling from a shower chair.
Findings
The facility failed to ensure adequate supervision to prevent accidents for three residents, resulting in severe adverse outcomes including a resident's death. Deficiencies were identified related to accident hazards, supervision, and care planning, with corrective actions implemented including staff training and competency evaluations.
Deficiencies (1)
Failure to ensure supervision to prevent accidents for residents resulting in severe adverse outcomes including death.
Report Facts
Residents reviewed for accidents: 4
Survey sample size: 7
Facility census: 86
Fall risk score: 75
Competency compliance: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E3 | Certified Nursing Assistant (CNA) | Assisted resident R1 during fall incident and provided care. |
| E13 | Certified Nursing Assistant (CNA) | Assessed resident R1's injury and described wound. |
| E14 | Certified Nursing Assistant (CNA) | Confirmed competency sign-offs. |
| E15 | Certified Nursing Assistant (CNA) | Confirmed competency sign-offs. |
| E16 | Staff Development Coordinator | Signed off on staff education and training. |
| E17 | Certified Nursing Assistant (CNA) | Confirmed staff education and competency. |
| E11 | Certified Nursing Assistant (CNA) | Interviewed regarding care and competency. |
| E8 | Registered Nurse (RN) | Confirmed CNAs should check Kardex each shift. |
| E9 | Certified Nursing Assistant (CNA) | Interviewed about care and Kardex checks. |
| E10 | Certified Nursing Assistant (CNA) | Interviewed about care and Kardex checks. |
| E12 | Certified Nursing Assistant (CNA) | Interviewed about care and fall incident. |
| E1 | Nursing Home Administrator (NHA) | Notified of fall incident and reviewed findings. |
| E2 | Director of Nursing (DON) | Notified of fall incident and reviewed findings. |
Inspection Report
Annual Inspection
Census: 78
Deficiencies: 15
Date: Aug 3, 2021
Visit Reason
An unannounced annual, complaint, and emergency preparedness survey was conducted at Gilpin Hall from July 19, 2021 through August 3, 2021 to assess compliance with regulatory requirements.
Complaint Details
The visit included complaint investigation related to allegations of sexual abuse by resident R42 against other residents. The complaint was substantiated as the facility failed to prevent further abuse and failed to immediately report the allegation. The facility also failed to thoroughly investigate and prevent further abuse during the investigation period.
Findings
The survey identified multiple deficiencies related to tuberculosis testing, influenza immunizations, resident abuse prevention, quality of care, medication management, infection control, nutrition, and safety protocols. The facility failed to meet several regulatory requirements, including documentation and procedural compliance in various areas.
Deficiencies (15)
Facility failed to ensure tuberculosis testing was performed on newly admitted residents and employees.
Facility failed to provide evidence that annual influenza vaccines were offered to employees.
Facility failed to ensure residents were free from sexual abuse; resident R42 was sexually abusive to other residents.
Facility failed to immediately report an allegation of abuse for resident R42.
Facility failed to thoroughly investigate allegations of abuse for residents R42 and R50.
Facility failed to prevent further potential abuse during investigation.
Facility failed to provide adequate supervision and care for residents with dementia and injuries.
Facility failed to ensure care plans were comprehensive and timely revised for sampled residents.
Facility failed to ensure residents received appropriate respiratory care and oxygen therapy.
Facility failed to ensure medication regimen reviews were conducted timely and thoroughly.
Facility failed to ensure food safety and sanitation standards were met in the kitchen.
Facility failed to ensure resident medical records were complete, accurate, and confidential.
Facility failed to ensure residents received pneumococcal and influenza immunizations as required.
Facility failed to ensure infection prevention and control procedures were properly followed.
Facility failed to ensure proper supervision and accident prevention devices were in place.
Report Facts
Facility census: 78
Survey sample size: 44
Employees reviewed for influenza vaccination: 15
Residents reviewed for abuse allegations: 4
Residents reviewed for care plan: 44
Residents reviewed for medication regimen: 5
Residents reviewed for nutrition: 2
Residents reviewed for oxygen therapy: 2
Employees reviewed for tuberculosis screening: 15
Employees reviewed for abuse training: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator (NHA) | Interviewed regarding tuberculosis testing and influenza vaccination findings |
| E2 | Director of Nursing (DON) | Interviewed regarding tuberculosis testing, abuse investigation, and care plan findings |
| E23 | Human Resources (HR) | Interviewed regarding tuberculosis screening for employees |
| E26 | Employee lacking evidence of tuberculosis screening | |
| E31 | Employee lacking evidence of tuberculosis screening | |
| E25 | Activity Aide | Employee lacking evidence of influenza vaccination |
| E28 | Certified Nursing Assistant (CNA) | Employee lacking evidence of influenza vaccination |
| E34 | Licensed Practical Nurse (LPN) | Employee lacking evidence of influenza vaccination |
| E36 | Housekeeper | Employee lacking evidence of influenza vaccination |
| E38 | Certified Nursing Assistant (CNA) | Employee lacking evidence of influenza vaccination |
| E42 | Resident Abuse related findings | |
| E45 | Therapy Director | Interviewed regarding resident supervision and abuse findings |
| E46 | Staff Coordinator | Witnessed abuse incident |
| E47 | Housekeeper | Witnessed abuse incident |
| E48 | Certified Nursing Assistant (CNA) | Witnessed abuse incident |
| E50 | Resident Abuse investigation | |
| E65 | Resident Abuse investigation | |
| E66 | Resident Abuse investigation | |
| E68 | Resident Abuse investigation | |
| E69 | Resident Abuse investigation | |
| E70 | Resident Abuse investigation | |
| E71 | Resident Abuse investigation | |
| E72 | Resident Abuse investigation | |
| E73 | Resident Abuse investigation | |
| E74 | Resident Abuse investigation | |
| E75 | Resident Abuse investigation | |
| E76 | Resident Abuse investigation | |
| E77 | Resident Abuse investigation | |
| E78 | Resident Abuse investigation | |
| E79 | Resident Abuse investigation | |
| E80 | Resident Abuse investigation | |
| E81 | Resident Abuse investigation | |
| E82 | Resident Abuse investigation | |
| E83 | Resident Abuse investigation | |
| E84 | Resident Abuse investigation | |
| E85 | Resident Abuse investigation | |
| E86 | Resident Abuse investigation | |
| E87 | Resident Abuse investigation | |
| E88 | Resident Abuse investigation | |
| E89 | Licensed Practical Nurse (LPN) | Staff Educator confirming training |
| E90 | Resident Abuse investigation |
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