Excelcare At Lewes Llc

F 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

altercations become physical. E15 stated that during this time she did not notify the social worker of the verbal altercations or feel that Resident R1 needed to be moved.11/12/25 3:00 PM - E4 (SW) stated during an

interview that she was not informed of any verbal altercations prior to the 11/2/25 incident and confirmed once the incident occurred Resident R1 was moved from the shared room.11/13/25 10:56 AM - E7 stated during an

interview that Resident R1 was moved to a different room after the physical altercation on 11/2/25. E7 stated that Resident R1 was vocal about his concerns regarding Resident R1 and anytime he was near Resident R2 would make statements saying there is the man [Resident R1] who pushed me down and he is too close to me.The facility failed to recognize escalating verbal altercations between Resident R1 and Resident R2, with lack of interventions the verbal altercations became physical on 11/2/25. The physical altercation resulted physical abuse, Resident R2 requiring hospitalization for injuries sustained and feelings of psychosocial harm. Resident R2 had feelings of fear related to Resident R1 related to being attacked in his own home.The facility had in-service training via electronic communication that started on 11/4/25 and was completed on 11/5/25. Additionally, the facility completed an in-person education that was initiated on 11/4/25 and provided signature sheets for all staff who completed. A roommate evaluation was completed on six residents with potential conflict and was concluded on 11/6/25 per documentation. Based

on the review of the facility's investigation, documented response, completion of training via electronic communication and in-person, resident interviews and evaluation, implementation of Resident R1 on 1:1 supervision, and staff interviews, the incidents related to E1 and E2 were determined to be past non-compliance. The plan of correction was initiated on 11/4/25 and completed on 11/5/25. 11/14/25 3:15 PM - Findings were reviewed with E1 (Corporate NHA), E2 (DON) and E3 (ADON) during the exit conference.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Excelcare at Lewes LLC

301 Ocean View Blvd Lewes, DE 19958

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on record review and interview, it was determined that for two (Resident R1 and Resident R6) out of seven residents reviewed for abuse, the facility failed to report resident to resident abuse to the State Agency within two hours. Findings include:1.Review of Resident R1's clinical record revealed:7/28/25 - Resident R1 was admitted to the facility.11/4/25 - A review of facility reported incident documented that Resident R1 experienced a psychotic episode and made contact with three residents (Resident R3, Resident R4, and Resident R5) which occurred on 11/3/25 at 9:00 PM. The incident report documented that the report was submitted to the state agency on 11/4/25 at 2:39 PM.11/7/25 9:30 AM - During an interview, E6 (CNA) confirmed the incident occurred on 11/3/25 at approximately 9:00 PM.11/13/25 12:10 PM - During an interview, E3 (ADON) confirmed that she was made aware an incident occurred on 11/3/25 around approximately 9:00 PM and stated that when obtaining staff interviews on 11/4/25 was then informed of Resident R1 having resident to resident physical contact with other residents. E3 stated the report was submitted late due to facility wanting to submit accurate data regarding

the incident. E3 confirmed the incident report was not submitted within the two hour time frame to the state agency.2. Review of Resident R6's clinical record revealed:10/27/25 - Resident R6 was admitted to the facility.11/3/25 - A progress note documented an IDT meeting was held regarding Resident R6 making fabricated statements and discussion of Resident R6 being moved to a different unit due to Resident R7 being in the room, not allowing for privacy to the roommate.11/14/25 12:50 PM - During an interview, E7 (CNA) revealed that Resident R6 stated that her husband Resident R7 choked her. E7 confirmed that this allegation of abuse was reported to the nurse, but E7 could not give recall the exact date of the allegation. 11/14/25 1:05 PM - During an interview, E11 (LPN) revealed that E7 reported the allegation of abuse between Resident R6 and Resident R7. E11 stated the allegation was reported to the nursing supervisor working that day and confirmed the process was to report allegations to supervisor and they would report to management. 11/14/25 2:10 PM - During an interview, E4 (SW) confirmed that an IDT meeting occurred and discussed Resident R6 making false statements in regards to Resident R7 and the family mentioned the history of the allegations during the meeting. E4 confirmed that statements were discussed during the IDT but unsure of the occurrence of them.11/14/25 2:32 PM - During an interview, E3 (ADON) confirmed she was present in the IDT meeting and stated that the family mentioned that Resident R6 had a history of making allegations about Resident R7. E3 stated she was not aware that Resident R6 alleged that Resident R7 choked her and staff did not report the allegation of abuse to her.11/14/25 3:15 PM - Findings were reviewed with E1 (Corporate NHA), E2 (DON) and E3 (ADON) during the exit conference.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Excelcare at Lewes LLC

301 Ocean View Blvd Lewes, DE 19958

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Based on record review and interview, it was determined that for one (Resident R2) out of seven (7) residents in the investigative sample, the facility failed to ensure the clinical record contained accurate documentation.

Findings include:Review of Resident R2's clinical record:7/1/25 - Resident R2 was admitted to the facility.11/7/25 - A review of Resident R1's clinical record lacked evidence of a progress note, consult, medication review, or visit summary after

the incident on 11/2/25. 11/13/25 1:25 PM - The facility provided electronic communication from E16 (NP) documenting Resident R2 was seen on 11/6/25 for a wellness check. 11/14/25 9:16 AM - During an interview, E12 (LPN) stated that Resident R2 had not been seen by psychiatrist on 11/6/25 and confirmed no progress notes were not in the electronic medical record for the aforementioned date. The facility failed to ensure the clinical

record contained accurate documentation. 11/14/25 - Findings were reviewed with E1 (Corporate NHA), E2 (DON) and E3 (ADON) during the exit conference.

Event ID:

Facility ID:

If continuation sheet