Gilpin Hall
Inspection Findings
F-Tag F0609
F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Based on interview, record review and review of the facility's policy and procedures, it was determined that for two (Resident R49 and Resident 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 Resident R49's clinical record revealed: 7/18/25 3:27 PM - An x-ray report was received by the facility which stated that Resident 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 Resident 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 Resident 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 Resident R90 and Resident 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
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
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
08/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gilpin Hall
1101 Gilpin Avenue Wilmington, DE 19806
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-Tag F0761
F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
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).
Event ID:
Facility ID:
If continuation sheet
GILPIN HALL in WILMINGTON, DE inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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.