Delaware Hospital DHCI: Immediate Jeopardy Safety - DE
The resident, identified in inspection records only as R2, had a cognitive assessment score of zero as of March 2025, meaning she could not participate in any interview about her own condition. She was completely dependent on staff for every activity of daily living and, according to her own certified nursing assistant, could not scoot or reposition herself at all.
On the night of May 11, a CNA was turning R2 toward the window when she reached across the bed for a washcloth. R2 rolled off the bed and hit the floor face down. She was sent to the emergency room that night with a cut above her right eyebrow and an abrasion on her right knee.
Two days later, a nurse documented that R2's right knee was swollen and warm, that she moaned and grimaced when it was touched, and that she could not bend it to 90 degrees. An X-ray ordered that afternoon confirmed what the symptoms already suggested: her right femur was fractured. She was transported by ambulance and had surgery. She returned to the facility on May 16.
The facility's own post-fall investigation, completed nearly five months after the fall, noted that R2 had never been placed on a fall prevention care plan because staff considered her incapable of moving herself. That assumption, the investigation made clear, did not account for what happens when a staff member turns a heavy, immobile resident toward a window and lets go.
Federal inspectors cited the facility for immediate jeopardy, the most serious level of harm under Medicare's enforcement framework. The Director of Nursing confirmed the findings on October 2. The nursing home administrator, director of nursing, and assistant director of nursing were present when inspectors reviewed the case at the exit conference on October 3.
R2's care plan now requires two staff members for any bed mobility. The CNA involved was sent back through new hire orientation before returning to independent work.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Delaware Hospital F/t Chronically Ill (dhci) from 2025-10-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 7, 2026 · Our methodology
DELAWARE HOSPITAL F/T CHRONICALLY ILL (DHCI) in SMYRNA, DE was cited for immediate jeopardy violations during a health inspection on October 3, 2025.
On the night of May 11, a CNA was turning R2 toward the window when she reached across the bed for a washcloth.
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.