Cycle 1
Health 2024-10-17 · Fire 2024-10-17
13 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Wilmington, DE
Gilpin Hall
3-star overall rating with 2-star inspections with abuse icon flag with 13 recent health deficiencies
1101 Gilpin Avenue, Wilmington, DE
(302) 654-4486
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
96
Certified beds
Average residents
92
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1997-01-07
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
0.66
Registered nurse staffing · state 1.03 · national 0.68
LPN hours / resident day
1.06
Licensed practical nurse staffing · state 1.01 · national 0.87
Aide hours / resident day
2.90
Nurse aide staffing · state 2.47 · national 2.35
Total nurse hours
4.62
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.72
RN + LPN hours · state 2.04 · national 1.54
Weekend hours
4.03
Weekend nurse staffing · state 4.04 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.72 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.15 · national 0.07
Adjusted RN hours
0.80
CMS adjusted RN staffing hours
Adjusted total hours
5.56
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
19%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
27%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,133
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
59.57
Composite VBP score used to determine payment impact.
Payment multiplier
1.0148
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.42
Baseline 21.60% · Performance 18.92% · Measure score 5.42 · Achievement 5.42 · Improvement 5.37
Healthcare-associated infections
2.86
Baseline 8.77% · Performance 7.51% · Measure score 2.86 · Achievement 1.10 · Improvement 2.86
Total nurse turnover
7.75
Baseline 32.63% · Performance 32.00% · Measure score 7.75 · Achievement 7.75 · Improvement 0.31
Adjusted total nurse staffing
7.79
Baseline 4.97 hours · Performance 5.30 hours · Measure score 7.79 · Achievement 7.79 · Improvement 3.53
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.49% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 67 · Observed rate 14.93% · Lower 95% interval 8.37% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| 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 29 · Denominator 29 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 29 |
| Discharge self-care score | 68.18% |
53.69%
14.5 pts better
|
Numerator 15 · Denominator 22 |
| Discharge mobility score | 59.09% |
50.94%
8.2 pts better
|
Numerator 13 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 3.45% |
2.29%
1.2 pts worse
|
Numerator 1 · Denominator 29 · Adjusted rate 2.25% |
| Healthcare-associated infections requiring hospitalization | 7.51% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 33 · Observed rate 9.09% · Lower 95% interval 3.74% |
| Staff COVID-19 vaccination coverage | 3.42% |
8.2%
4.8 pts worse
|
Numerator 5 · Denominator 146 |
| Staff flu vaccination coverage | 45.22% |
42%
3.2 pts better
|
Numerator 71 · Denominator 157 |
| Discharge function score | 68.18% |
56.45%
11.7 pts better
|
Numerator 15 · Denominator 22 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
1.8
0.9 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 1.7 · Expected 1.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
1.4
1 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 1.7 · Expected 1.1 · 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 | 3.5% |
3.2%
0.3 pts worse
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.2% · Q3 3.3% · Q4 4.3% · 4Q avg 3.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
5.6%
0.3 pts worse
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 5.9% · Q3 7.6% · Q4 8.8% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.2% |
21.1%
0.1 pts worse
|
19.6%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.0% · Q2 21.2% · Q3 20.2% · Q4 22.4% · 4Q avg 21.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.0% |
12.0%
4 pts better
|
16.7%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 5.3% · Q3 7.0% · Q4 9.2% · 4Q avg 8.0% · 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 ability to walk independently worsened | 11.4% |
17.5%
6.1 pts better
|
16.3%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 15.3% · Q3 1.8% · Q4 9.9% · 4Q avg 11.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.7% |
14.7%
4 pts worse
|
14.9%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 20.0% · Q3 11.4% · Q4 24.1% · 4Q avg 18.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
0.7%
0.7 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 2.3% · Q4 2.2% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.8% |
2.0%
3.8 pts worse
|
1.7%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 2.2% · Q3 9.1% · Q4 5.5% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.6% |
21.6%
5 pts worse
|
19.8%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 28.6% · Q3 20.8% · Q4 31.2% · 4Q avg 26.6% |
| Percentage of long-stay residents with pressure ulcers | 3.4% |
4.4%
1 pts better
|
5.1%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 2.3% · Q3 4.0% · Q4 2.6% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
83.5%
16.5 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 31.7% |
11.2%
20.5 pts worse
|
12.0%
19.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.7% · Observed 26.9% · Expected 9.5% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 7.5% |
21.5%
14 pts better
|
23.9%
16.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.5% · Observed 7.7% · Expected 24.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-14 · Fire 2023-12-14
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-08-03 · Fire 2021-08-03
13 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-03
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2025-12-29
D · Potential for more than minimal harm
2025-12-03
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-12-29
D · Potential for more than minimal harm
2025-08-29
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 2025-10-13
D · Potential for more than minimal harm
2025-08-29
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 2025-10-13
E · Potential for more than minimal harm
2024-10-17
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-11-10
E · Potential for more than minimal harm
2024-10-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-10
D · Potential for more than minimal harm
2024-10-17
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 2024-11-10
D · Potential for more than minimal harm
2024-10-17
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-11-10
D · Potential for more than minimal harm
2024-10-17
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-11-10
D · Potential for more than minimal harm
2024-10-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-10
D · Potential for more than minimal harm
2024-10-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-10
D · Potential for more than minimal harm
2024-10-17
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 2024-11-10
D · Potential for more than minimal harm
2024-10-17
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-11-10
E · Potential for more than minimal harm
2023-12-14
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-01-31
D · Potential for more than minimal harm
2023-12-14
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 2024-01-31
D · Potential for more than minimal harm
2023-12-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-31
F · Potential for more than minimal harm
2021-08-03
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2021-10-01
F · Potential for more than minimal harm
2021-08-03
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 2021-10-01
E · Potential for more than minimal harm
2021-08-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-10-01
E · Potential for more than minimal harm
2021-08-03
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 2021-10-01
D · Potential for more than minimal harm
2021-08-03
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 2021-10-01
D · Potential for more than minimal harm
2021-08-03
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2021-10-01
D · Potential for more than minimal harm
2021-08-03
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 2021-10-01
D · Potential for more than minimal harm
2021-08-03
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-10-01
D · Potential for more than minimal harm
2021-08-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-10-01
D · Potential for more than minimal harm
2021-08-03
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 2021-10-01
D · Potential for more than minimal harm
2021-08-03
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-10-01
D · Potential for more than minimal harm
2021-08-03
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2021-10-01
B · Minimal harm
2021-08-03
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 2021-10-01
Penalties and ownership
What sits behind the stars
Ownership
Bannan, Jessica
W-2 Managing Employee · Individual
Clark, Stephen
Corporate Director · Individual
Clark, Stephen
Corporate Officer · Individual
Guggenberger, Paul
Corporate Director · Individual
Guggenberger, Paul
Corporate Officer · Individual
Lind, Gail
Corporate Director · Individual
Mcbride, Terrence
Corporate Director · Individual
Reese, C
Corporate Director · Individual
Smiley, Paul
W-2 Managing Employee · Individual
Smith, Harvey
Corporate Director · Individual
Smith, Harvey
Corporate Officer · Individual
Smith, Matthew
Corporate Director · Individual
Smith, Matthew
Corporate Officer · Individual
Warrington, Alan
Contracted Managing Employee · Individual
Wolcott, Daniel
Corporate Director · Individual
Wolcott, Daniel
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Regency Healthcare & Rehab Center
Wilmington, DE
4-star overall rating with 4-star inspections with $226,471 in total fines with 2 recent health deficiencies
#2
Kentmere Rehabilitation And Healthcare Center
Wilmington, DE
3-star overall rating with 2-star inspections with 20 recent health deficiencies
#3
Excelcare At Wilmington LLC
Wilmington, DE
3-star overall rating with 2-star inspections with abuse icon flag with $38,290 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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