Delaware Bay Rehab: Pressure Ulcer Harm Found - DE
The deterioration wasn't sudden. It was documented, step by step, across weeks of delayed orders and missed appointments.
A nurse, identified in the inspection report as E3, initiated an order for a low air loss mattress on September 4. The order wasn't entered until September 17. There was no evidence the mattress was ever put in place on the day she requested it. Thirteen days passed while the resident lay without it.
The wound care physician, E8, was scheduled to see the resident on September 9 but didn't, because the resident had been taken to an outside appointment that day. E8 didn't assess the resident until September 16, when Silvadene cream was finally ordered. A follow-up visit happened September 23. By then, the wound assessment showed purulent drainage. E8 made no changes to the treatment and ordered nothing to address the infection.
By the time inspectors arrived on October 22, E3 confirmed what the record showed: the edges of the wounds were lifting. The centers were hard and necrotic.
The findings were reviewed with the Director of Nursing during the exit conference. The inspection was rated as causing actual harm to the resident.
The resident entered the facility needing wound care. What they got, across the first two weeks of their stay, was a mattress order that sat unfilled for nearly a fortnight and a physician visit that didn't happen when it was supposed to. By the time anyone looked closely enough to act, the wound that brought them there had become two wounds that couldn't be staged at all.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Delaware Bay Rehabilitation and Healthcare Center from 2025-10-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
DELAWARE BAY REHABILITATION AND HEALTHCARE CENTER in GEORGETOWN, DE was cited for violations during a health inspection on October 22, 2025.
The deterioration wasn't sudden.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.