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Complaint Investigation

Gilpin Hall

August 29, 2025 · Wilmington, DE · 1101 Gilpin Avenue
Citations 2
CMS Rating 3/5
Beds 96
Provider ID 085047
Healthcare Facility
Gilpin Hall
Wilmington, DE  ·  View full profile →
Inspection Summary

GILPIN HALL in WILMINGTON, DE — inspection on August 29, 2025.

Found 2 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.

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Inspection Findings

FF0609
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Potential for More Than Minimal Harm

Based on interview, record review and review of the facility's policy and procedures, it was determined that for two (R49 and R90) out of six residents reviewed for abuse, the facility failed to report the allegations of abuse and injury of unknown origin within the two-hour requirement.

Findings include:1.

Review of R49's clinical record revealed: 7/18/25 3:27 PM - An x-ray report was received by the facility which stated that R49 had an acute hand fracture. 7/21/25 12:53 PM -

Review of the State Agency's Incident Summary Report documented that the facility reported R49's injury of unknown origin, a hand fracture, approximately three days later. 8/28/25 2:40 PM -

During an interview, surveyor reviewed finding with E2 (DON). E2 stated she wasn't aware of this and would look at it. 2.

Review of R90's clinical record revealed: 6/4/25 10:00 AM The facility's incident report documented an allegation of resident-to-resident abuse between R90 and R62. 6/4/25 1:59 PM -

Review of the State Agency's Incident Summary Report documented that that the facility reported the incident approximately four hours after the altercation.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/29/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Gilpin Hall

1101 Gilpin Avenue Wilmington, DE 19806

SUMMARY STATEMENT OF DEFICIENCIES

Based on observation and interview, it was determined for two out of two medication rooms reviewed for storage of controlled substances, the facility failed to ensure that the locked boxes were permanently affixed to medication room refrigerators.8/27/25 10:12 AM - During a tour of the second-floor medication room, the storage box for the controlled substances was observed on top of the refrigerator.

The third-floor controlled substances box was observed in refrigerator, but it was not permanently affixed. 8/28/25 9:30 AM - The second-floor medication room, the storage box for the controlled substances continued to be on top of the refrigerator.

The third-floor controlled substances box continued to be in the refrigerator, but it not permanently affixed. 8/28/25 10:00 AM -

During an interview E14 (RN) stated, The controlled substances that have to be refrigerated are kept in the refrigerators and counted every shift. 8/29/25 2:30 PM - The findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E5 (ADON).

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WILMINGTON, DE, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GILPIN HALL or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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