Cycle 1
Health 2024-07-02 · Fire 2024-07-02
21 health deficiencies
Top issue: Resident Assessment and Care Planning (7 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Wilmington, DE
Encore At Wilmington
2-star overall rating with 1-star inspections with $32,394 in total fines with 21 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
2723 Shipley Road, Wilmington, DE
(302) 479-0111
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
82
Certified beds
Average residents
65
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1986-05-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.90
Registered nurse staffing
LPN hours / resident day
0.95
Licensed practical nurse staffing
Aide hours / resident day
2.10
Nurse aide staffing
Weekend hours
3.68
Weekend nurse staffing
RN turnover
44%
Annual RN turnover
Total nurse turnover
50%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.8
0.3 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.4
0.8 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
95.7%
2.7 pts better
|
93.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.9% |
97.4%
0.5 pts better
|
95.5%
2.4 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.5% |
3.2%
2.7 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.5%
6.5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 9.7% |
5.6%
4.1 pts worse
|
5.4%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.5% |
21.1%
7.6 pts better
|
19.6%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 2.2% |
12.0%
9.8 pts better
|
16.7%
14.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 23.6% |
17.5%
6.1 pts worse
|
16.3%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.8% |
14.7%
3.1 pts worse
|
14.9%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 4.9% |
2.0%
2.9 pts worse
|
1.7%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.9% |
21.6%
2.3 pts worse
|
19.8%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
4.4%
0.5 pts worse
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.3% |
83.5%
6.8 pts better
|
81.7%
8.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.4% |
11.2%
4.8 pts better
|
12.0%
5.6 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
0.9%
About the same
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.2% |
83.1%
6.1 pts better
|
79.7%
9.5 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.0% |
21.5%
7.5 pts better
|
23.9%
9.9 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-26 · Fire 2023-01-26
24 health deficiencies
Top issue: Infection Control (5 deficiencies)
1 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2019-11-01 · Fire 2019-11-01
15 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-02
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-09-17
E · Potential for more than minimal harm
2024-07-02
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-09-17
E · Potential for more than minimal harm
2024-07-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-17
E · Potential for more than minimal harm
2024-07-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-17
D · Potential for more than minimal harm
2024-07-02
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-08-09
E · Potential for more than minimal harm
2023-01-26
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-03-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-06
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-07-16
G · Actual harm
2024-07-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-07-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-09
E · Potential for more than minimal harm
2024-07-02
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-02
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-02
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-02
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-02
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-02
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-02
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-02
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-02
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-02
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-02
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-07-02
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-02
F728 · Nursing and Physician Services Deficiencies
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-02
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-02
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-02
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-02
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-02
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-08-09
C · Minimal harm
2024-07-02
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2024-08-09
J · Immediate jeopardy
2024-01-08
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-02-05
E · Potential for more than minimal harm
2024-01-08
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-02-05
D · Potential for more than minimal harm
2024-01-08
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-02-05
D · Potential for more than minimal harm
2024-01-08
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-02-05
D · Potential for more than minimal harm
2024-01-08
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-02-05
D · Potential for more than minimal harm
2024-01-08
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-02-05
D · Potential for more than minimal harm
2024-01-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-05
D · Potential for more than minimal harm
2024-01-08
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-02-05
D · Potential for more than minimal harm
2024-01-08
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-02-05
D · Potential for more than minimal harm
2024-01-08
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-02-05
D · Potential for more than minimal harm
2023-04-20
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-05-16
D · Potential for more than minimal harm
2023-04-20
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2023-05-16
F · Potential for more than minimal harm
2023-01-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-02-21
F · Potential for more than minimal harm
2023-01-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-21
F · Potential for more than minimal harm
2023-01-26
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-02-21
F · Potential for more than minimal harm
2023-01-26
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2023-02-21
E · Potential for more than minimal harm
2023-01-26
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-02-21
E · Potential for more than minimal harm
2023-01-26
F885 · Infection Control Deficiencies
Health
Report COVID19 data to residents and families.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-26
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-26
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-26
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-26
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-26
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-26
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-26
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-26
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-26
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-26
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-26
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-26
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2023-02-21
C · Minimal harm
2023-01-26
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-02-21
E · Potential for more than minimal harm
2019-11-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-11-22
D · Potential for more than minimal harm
2019-11-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-11-22
D · Potential for more than minimal harm
2019-11-01
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-11-22
Penalties and ownership
What sits behind the stars
$16,801
2024-07-02
Fine
Fine · fine $16,801
Fine
$15,593
2024-01-08
Fine
Fine · fine $15,593
Fine
Ownership
Snh Proj Lincoln Trs LLC
5% Or Greater Direct Ownership Interest · Organization
Anderson, Jacquelyn
Corporate Officer · Individual
Ballas, Timothy
Contracted Managing Employee · Individual
Bilotto, Christopher
Corporate Officer · Individual
Blackrock Inc
5% Or Greater Indirect Ownership Interest · Organization
Boide, William
Contracted Managing Employee · Individual
Brown, Matthew
Corporate Officer · Individual
Clark, Jennifer
Corporate Officer · Individual
Diversified Healthcare Trust
5% Or Greater Indirect Ownership Interest · Organization
Harmon, Crystal
Contracted Managing Employee · Individual
Life Care Services LLC
Operational/Managerial Control · Organization
Mcghee, Karen
Contracted Managing Employee · Individual
Snh Trs Licensee Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Snh Trs, Inc.
5% Or Greater Indirect Ownership Interest · Organization
State Street Corporation
5% Or Greater Indirect Ownership Interest · Organization
Vanguard Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
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Cadia Rehabilitation Silverside
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#2
Encore At Windsor Hills
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5-star overall rating with 4-star inspections with $19,837 in total fines with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Wilmington Nursing & Rehabilitation Center
Wilmington, DE
1-star overall rating with 1-star inspections with Special Focus status with $408,742 in total fines with 27 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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