Cycle 1
Health 2024-11-22 · Fire 2024-11-22
20 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Wilmington, DE
Kentmere Rehabilitation And Healthcare Center
3-star overall rating with 2-star inspections with 20 recent health deficiencies
1900 Lovering Avenue, Wilmington, DE
(302) 652-3311
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
104
Certified beds
Average residents
91
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
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
0.88
Registered nurse staffing · state 1.03 · national 0.68
LPN hours / resident day
1.00
Licensed practical nurse staffing · state 1.01 · national 0.87
Aide hours / resident day
2.49
Nurse aide staffing · state 2.47 · national 2.35
Total nurse hours
4.38
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.88
RN + LPN hours · state 2.04 · national 1.54
Weekend hours
4.00
Weekend nurse staffing · state 4.04 · national 3.43
Weekend RN hours
0.68
Weekend registered nurse coverage · state 0.72 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.15 · national 0.07
Adjusted RN hours
1.01
CMS adjusted RN staffing hours
Adjusted total hours
5.01
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,285
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.56
Composite VBP score used to determine payment impact.
Payment multiplier
0.9935
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.41
Baseline 17.90% · Performance 19.85% · Measure score 3.41 · Achievement 3.41 · Improvement 0
Healthcare-associated infections
4.92
Baseline 4.68% · Performance 6.37% · Measure score 4.92 · Achievement 4.92 · Improvement 0
Total nurse turnover
4.19
Baseline 44.21% · Performance 46.53% · Measure score 4.19 · Achievement 4.19 · Improvement 0
Adjusted total nurse staffing
3.7
Baseline 3.93 hours · Performance 4.13 hours · Measure score 3.7 · Achievement 3.7 · Improvement 0.57
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.49% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 172 · Observed rate 6.98% · Lower 95% interval 6.75% |
| Discharge to community | 56.45% |
50.57%
5.9 pts better
|
No Different than the National Rate · Eligible stays 159 · Observed rate 49.06% · Lower 95% interval 48.44% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 106 · Denominator 106 |
| Falls with major injury | 3.77% |
0.77%
3 pts worse
|
Numerator 4 · Denominator 106 |
| Discharge self-care score | 63.75% |
53.69%
10.1 pts better
|
Numerator 51 · Denominator 80 |
| Discharge mobility score | 57.5% |
50.94%
6.6 pts better
|
Numerator 46 · Denominator 80 |
| Pressure ulcers or injuries, new or worsened | 2.83% |
2.29%
0.5 pts worse
|
Numerator 3 · Denominator 106 · Adjusted rate 2.85% |
| Healthcare-associated infections requiring hospitalization | 6.37% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 126 · Observed rate 5.56% · Lower 95% interval 3.65% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 160 |
| Staff flu vaccination coverage | 28.83% |
42%
13.2 pts worse
|
Numerator 47 · Denominator 163 |
| Discharge function score | 62.5% |
56.45%
6 pts better
|
Numerator 50 · Denominator 80 |
| Transfer of health information to provider | 89.29% |
95.95%
6.7 pts worse
|
Numerator 25 · Denominator 28 |
| Transfer of health information to patient | 95.83% |
96.28%
0.5 pts worse
|
Numerator 46 · Denominator 48 |
| Resident COVID-19 vaccinations up to date | 17.31% |
25.2%
7.9 pts worse
|
Numerator 9 · Denominator 52 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.8
0.5 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 1.8 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.4
0.4 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.3% |
95.7%
8.4 pts worse
|
93.4%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 87.4% · Q2 91.5% · Q3 89.0% · Q4 81.6% · 4Q avg 87.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.6% |
97.4%
1.8 pts worse
|
95.5%
0.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.4% |
3.2%
1.2 pts worse
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 2.4% · Q3 4.9% · Q4 4.6% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
6.5%
6.2 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 7.4% |
5.6%
1.8 pts worse
|
5.4%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 14.5% · Q3 3.9% · Q4 4.9% · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.9% |
21.1%
9.2 pts better
|
19.6%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 16.9% · Q3 7.9% · Q4 10.8% · 4Q avg 11.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.8% |
12.0%
7.2 pts better
|
16.7%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 4.6% · Q3 2.9% · Q4 1.4% · 4Q avg 4.8% · 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 | 24.9% |
17.5%
7.4 pts worse
|
16.3%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.8% · Q2 33.5% · Q3 24.7% · Q4 23.6% · 4Q avg 24.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.4% |
14.7%
5.7 pts worse
|
14.9%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 23.6% · Q3 15.7% · Q4 22.1% · 4Q avg 20.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.7%
0.4 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.6% |
2.0%
1.6 pts worse
|
1.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 3.7% · Q3 1.2% · Q4 3.5% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.9% |
21.6%
4.3 pts worse
|
19.8%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.2% · Q2 29.8% · Q3 20.3% · Q4 19.7% · 4Q avg 25.9% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
4.4%
0.7 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 1.1% · Q3 3.9% · Q4 6.5% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.1% |
83.5%
7.4 pts worse
|
81.7%
5.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 77.9% · Q2 83.1% · Q3 75.0% · Q4 64.4% · 4Q avg 76.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.9% |
11.2%
3.3 pts better
|
12.0%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.9% · Observed 7.6% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
0.9%
0.9 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.3% · Q4 4.8% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.6% |
83.1%
1.5 pts better
|
79.7%
4.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.6% |
21.5%
3.9 pts better
|
23.9%
6.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.6% · Observed 17.7% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-12 · Fire 2023-10-12
12 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-12-09 · Fire 2021-12-09
12 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-10-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-10-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-11-20
Inspection history
Recent health citations
G · Actual harm
2025-12-13
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 2026-02-11
E · Potential for more than minimal harm
2025-12-13
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 2026-02-11
D · Potential for more than minimal harm
2025-12-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2026-02-11
D · Potential for more than minimal harm
2025-12-13
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2026-02-11
F · Potential for more than minimal harm
2024-11-22
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 2025-01-29
F · Potential for more than minimal harm
2024-11-22
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 2025-01-29
E · Potential for more than minimal harm
2024-11-22
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 2025-01-29
E · Potential for more than minimal harm
2024-11-22
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-11-22
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-11-22
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-11-22
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 2025-01-29
D · Potential for more than minimal harm
2024-11-22
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-11-22
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 2025-01-29
D · Potential for more than minimal harm
2024-11-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-11-22
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 2025-01-29
D · Potential for more than minimal harm
2024-11-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-11-22
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-11-22
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 2025-01-29
D · Potential for more than minimal harm
2024-11-22
F741 · Quality of Life and Care Deficiencies
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-11-22
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-01-29
F · Potential for more than minimal harm
2023-10-12
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 2023-12-13
E · Potential for more than minimal harm
2023-10-12
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 2023-12-13
E · Potential for more than minimal harm
2023-10-12
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2023-12-13
E · Potential for more than minimal harm
2023-10-12
F848 · Administration Deficiencies
Health
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Corrected 2023-12-13
E · Potential for more than minimal harm
2023-10-12
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 2023-12-13
D · Potential for more than minimal harm
2023-10-12
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 2023-12-13
D · Potential for more than minimal harm
2023-10-12
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 2023-12-13
D · Potential for more than minimal harm
2023-10-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-12-13
D · Potential for more than minimal harm
2023-10-12
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 2023-12-13
D · Potential for more than minimal harm
2023-10-12
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-12-13
D · Potential for more than minimal harm
2023-10-12
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-12-13
D · Potential for more than minimal harm
2023-10-12
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 2023-12-13
K · Immediate jeopardy
2021-12-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-01-07
F · Potential for more than minimal harm
2021-12-09
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2022-01-07
E · Potential for more than minimal harm
2021-12-09
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 2022-01-07
E · Potential for more than minimal harm
2021-12-09
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 2022-01-07
E · Potential for more than minimal harm
2021-12-09
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 2022-01-07
D · Potential for more than minimal harm
2021-12-09
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2022-01-07
D · Potential for more than minimal harm
2021-12-09
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 2022-01-07
D · Potential for more than minimal harm
2021-12-09
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 2022-01-07
D · Potential for more than minimal harm
2021-12-09
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 2022-01-07
D · Potential for more than minimal harm
2021-12-09
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 2022-01-07
D · Potential for more than minimal harm
2021-12-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-01-07
D · Potential for more than minimal harm
2021-12-09
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2022-01-07
Penalties and ownership
What sits behind the stars
Ownership
Kentmere Rehabilitation And Healthcare Center Inc
5% Or Greater Direct Ownership Interest · Organization
Mahler, Eileen
Corporate Director · Individual
Mahler, Eileen
W-2 Managing Employee · Individual
Nearby options
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#3
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