Wilmington, DE

Encore At Windsor Hills

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

1212 Foulk Road, Wilmington, DE

(302) 478-4296

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

46

Certified beds

Average residents

44

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

2022-08-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

1.25

Registered nurse staffing · state 1.03 · national 0.68

LPN hours / resident day

0.61

Licensed practical nurse staffing · state 1.01 · national 0.87

Aide hours / resident day

2.59

Nurse aide staffing · state 2.47 · national 2.35

Total nurse hours

4.45

All reported nurse hours · state 4.51 · national 3.89

Licensed hours

1.87

RN + LPN hours · state 2.04 · national 1.54

Weekend hours

3.96

Weekend nurse staffing · state 4.04 · national 3.43

Weekend RN hours

0.76

Weekend registered nurse coverage · state 0.72 · national 0.47

Physical therapist

0.09

Reported PT staffing · state 0.15 · national 0.07

Adjusted RN hours

1.24

CMS adjusted RN staffing hours

Adjusted total hours

4.42

CMS adjusted total nurse staffing hours

Case-mix index

1.38

Higher values indicate more complex resident acuity

RN turnover

17%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

13%

Annual nurse turnover · state 42% · national 46%

SNF VBP

Value-based purchasing

Program rank

828

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

63.21

Composite VBP score used to determine payment impact.

Payment multiplier

1.0180

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.82

Performance 19.20% · Measure score 4.82 · Achievement 4.82 · This facility did not have sufficient data to calculate a baseline period measure result.

Healthcare-associated infections

5.35

Performance 6.24% · Measure score 5.35 · Achievement 5.35 · This facility did not have sufficient data to calculate a baseline period measure result.

Total nurse turnover

10

Performance 9.76% · Measure score 10 · Achievement 10 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

5.12

Performance 4.53 hours · Measure score 5.12 · Achievement 5.12 · This facility did not have sufficient data to calculate a baseline period measure result.

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.23%	10.72% 0.5 pts better	No Different than the National Rate · Eligible stays 82 · Observed rate 7.32% · Lower 95% interval 6.79%
Discharge to community	52.2%	50.57% 1.6 pts better	No Different than the National Rate · Eligible stays 73 · Observed rate 46.58% · Lower 95% interval 40.81%
Medicare spending per beneficiary	0.81	1.02 0.2 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 76 · Denominator 76
Falls with major injury	1.32%	0.77% 0.6 pts worse	Numerator 1 · Denominator 76
Discharge self-care score	64.52%	53.69% 10.8 pts better	Numerator 40 · Denominator 62
Discharge mobility score	58.06%	50.94% 7.1 pts better	Numerator 36 · Denominator 62
Pressure ulcers or injuries, new or worsened	1.32%	2.29% 1 pts better	Numerator 1 · Denominator 76 · Adjusted rate 1.27%
Healthcare-associated infections requiring hospitalization	6.24%	7.12% 0.9 pts better	No Different than the National Rate · Eligible stays 65 · Observed rate 3.08% · Lower 95% interval 3.1%
Staff COVID-19 vaccination coverage	2.84%	8.2% 5.4 pts worse	Numerator 4 · Denominator 141
Staff flu vaccination coverage	11.68%	42% 30.3 pts worse	Numerator 23 · Denominator 197
Discharge function score	58.06%	56.45% 1.6 pts better	Numerator 36 · Denominator 62
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 46 · Denominator 46
Resident COVID-19 vaccinations up to date	51.11%	25.2% 25.9 pts better	Numerator 23 · Denominator 45

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.4	1.8 0.4 pts better	1.9 0.5 pts better	Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 0.9 · Expected 1.2 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.3	1.4 1.1 pts better	1.8 1.5 pts better	Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.2 · Expected 1.2 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	95.7% 4.3 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	97.4% 2.6 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	1.5%	3.2% 1.7 pts better	3.3% 1.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.4% · Q4 3.3% · 4Q avg 1.5% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	7.9%	6.5% 1.4 pts worse	11.4% 3.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 6.2% · Q3 6.9% · Q4 6.7% · 4Q avg 7.9%
Percentage of long-stay residents who lose too much weight	5.6%	5.6% About the same	5.4% 0.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.3% · Q3 4.8% · Q4 9.1% · 4Q avg 5.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	31.9%	21.1% 10.8 pts worse	19.6% 12.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 32.0% · Q3 38.1% · Q4 30.4% · 4Q avg 31.9%
Percentage of long-stay residents who received an antipsychotic medication	10.4%	12.0% 1.6 pts better	16.7% 6.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.0% · 4Q avg 10.4% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose need for help with daily activities has increased	10.0%	14.7% 4.7 pts better	14.9% 4.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 23.8% · 4Q avg 10.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	2.5%	0.7% 1.8 pts worse	1.0% 1.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.1% · Q3 2.9% · Q4 2.2% · 4Q avg 2.5% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	3.1%	2.0% 1.1 pts worse	1.7% 1.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 3.4% · Q4 6.7% · 4Q avg 3.1% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	19.2%	21.6% 2.4 pts better	19.8% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 23.2% · Q2 12.6% · Q3 10.7% · Q4 30.6% · 4Q avg 19.2%
Percentage of long-stay residents with pressure ulcers	0.9%	4.4% 3.5 pts better	5.1% 4.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 1.9% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	98.8%	83.5% 15.3 pts better	81.7% 17.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 98.4% · Q3 99.0% · Q4 99.1% · 4Q avg 98.8%
Percentage of short-stay residents who had an outpatient emergency department visit	3.7%	11.2% 7.5 pts better	12.0% 8.3 pts better	Short Stay · 20240701-20250630 · Adjusted 3.7% · Observed 3.3% · Expected 9.9% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 1.4% · 4Q avg 0.9% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	100.0%	83.1% 16.9 pts better	79.7% 20.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	27.7%	21.5% 6.2 pts worse	23.9% 3.8 pts worse	Short Stay · 20240701-20250630 · Adjusted 27.7% · Observed 23.3% · Expected 20.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-02-26 · Fire 2024-02-26

7 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

7 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Cycle 2 Health 2022-05-27 · Fire 2022-05-27

11 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health · Fire

1 health deficiencies

Top issue: Resident Assessment and Care Planning (1 deficiency)

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 2024-02-26

K131 · Construction Deficiencies

Fire Safety

Meet requirements for sections of health care facilities separated by fire resistive construction.

Corrected 2024-04-16

E · Potential for more than minimal harm 2024-02-26

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2024-04-16

E · Potential for more than minimal harm 2024-02-26

K232 · Egress Deficiencies

Fire Safety

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Corrected 2024-04-16

E · Potential for more than minimal harm 2024-02-26

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-04-16

E · Potential for more than minimal harm 2024-02-26

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-04-16

E · Potential for more than minimal harm 2024-02-26

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-04-16

E · Potential for more than minimal harm 2024-02-26

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2024-04-16

Inspection history

Recent health citations

G · Actual harm 2024-02-26

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 2023-07-05

F · Potential for more than minimal harm 2024-02-26

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 2024-04-01

D · Potential for more than minimal harm 2024-02-26

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 2024-04-01

D · Potential for more than minimal harm 2024-02-26

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 2024-04-01

D · Potential for more than minimal harm 2024-02-26

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-04-01

D · Potential for more than minimal harm 2024-02-26

F712 · Nursing and Physician Services Deficiencies

Health

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Corrected 2024-04-01

D · Potential for more than minimal harm 2024-02-26

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 2024-04-01

D · Potential for more than minimal harm 2024-02-26

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2024-04-01

E · Potential for more than minimal harm 2022-05-27

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2022-07-05

E · Potential for more than minimal harm 2022-05-27