Excelcare At Lewes Llc
EXCELCARE AT LEWES LLC in LEWES, DE — inspection on November 14, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
altercations become physical. E15 stated that during this time she did not notify the social worker of the verbal altercations or feel that 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 R1 was moved from the shared room.11/13/25 10:56 AM - E7 stated during an interview that R1 was moved to a different room after the physical altercation on 11/2/25. E7 stated that R1 was vocal about his concerns regarding R1 and anytime he was near R2 would make statements saying there is the man [R1] who pushed me down and he is too close to me.
The facility failed to recognize escalating verbal altercations between R1 and R2, with lack of interventions the verbal altercations became physical on 11/2/25.
The physical altercation resulted physical abuse, R2 requiring hospitalization for injuries sustained and feelings of psychosocial harm. R2 had feelings of fear related to 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 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/14/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Excelcare at Lewes LLC
301 Ocean View Blvd Lewes, DE 19958
SUMMARY STATEMENT OF DEFICIENCIES
Based on record review and interview, it was determined that for two (R1 and 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 R1's clinical record revealed:7/28/25 - R1 was admitted to the facility.11/4/25 - A review of facility reported incident documented that R1 experienced a psychotic episode and made contact with three residents (R3, R4, and 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 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 R6's clinical record revealed:10/27/25 - R6 was admitted to the facility.11/3/25 - A progress note documented an IDT meeting was held regarding R6 making fabricated statements and discussion of R6 being moved to a different unit due to 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 R6 stated that her husband 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 R6 and 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 R6 making false statements in regards to 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 R6 had a history of making allegations about R7. E3 stated she was not aware that R6 alleged that 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/14/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Excelcare at Lewes LLC
301 Ocean View Blvd Lewes, DE 19958
SUMMARY STATEMENT OF DEFICIENCIES
Based on record review and interview, it was determined that for one (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 R2's clinical record:7/1/25 - R2 was admitted to the facility.11/7/25 - A review of 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 R2 was seen on 11/6/25 for a wellness check. 11/14/25 9:16 AM -
During an interview, E12 (LPN) stated that 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.
Facility ID: