Cycle 1
Health 2025-07-01 · Fire 2025-07-01
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Wilmington, DE
Regency Healthcare & Rehab Center
4-star overall rating with 4-star inspections with $226,471 in total fines with 2 recent health deficiencies
801 N. Broom Street, Wilmington, DE
(302) 654-8400
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
89
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nationwide Healthcare Services
Operator or chain grouping
Approved since
1970-06-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
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
0.67
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
2.14
Nurse aide staffing · state 2.47 · national 2.35
Total nurse hours
3.87
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.73
RN + LPN hours · state 2.04 · national 1.54
Weekend hours
3.58
Weekend nurse staffing · state 4.04 · national 3.43
Weekend RN hours
0.50
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
0.75
CMS adjusted RN staffing hours
Adjusted total hours
4.35
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
45%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,771
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.37
Composite VBP score used to determine payment impact.
Payment multiplier
0.9815
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
0
Baseline 7.22% · Performance 8.75% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 49.49% · Performance 62.40% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
4.61
Baseline 4.15 hours · Performance 4.39 hours · Measure score 4.61 · Achievement 4.61 · Improvement 0.97
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.36% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 62 · Observed rate 9.68% · Lower 95% interval 7.2% |
| Discharge to community | 50.31% |
50.57%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 32 · Observed rate 37.5% · Lower 95% interval 34.88% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 95% |
95.27%
0.3 pts worse
|
Numerator 38 · Denominator 40 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 40 |
| Discharge self-care score | 59.26% |
53.69%
5.6 pts better
|
Numerator 16 · Denominator 27 |
| Discharge mobility score | 44.44% |
50.94%
6.5 pts worse
|
Numerator 12 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 7.5% |
2.29%
5.2 pts worse
|
Numerator 3 · Denominator 40 · Adjusted rate 5.5% |
| Healthcare-associated infections requiring hospitalization | 8.75% |
7.12%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 27 · Observed rate 18.52% · Lower 95% interval 4.49% |
| Staff COVID-19 vaccination coverage | 8.7% |
8.2%
0.5 pts better
|
Numerator 10 · Denominator 115 |
| Staff flu vaccination coverage | 45.9% |
42%
3.9 pts better
|
Numerator 56 · Denominator 122 |
| Discharge function score | 51.85% |
56.45%
4.6 pts worse
|
Numerator 14 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 61.9% |
25.2%
36.7 pts better
|
Numerator 13 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.8
0.1 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.7 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.2 |
1.4
1.8 pts worse
|
1.8
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 2.8 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
95.7%
3.4 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 98.8% · Q3 100.0% · Q4 100.0% · 4Q avg 99.1% |
| 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 | 2.4% |
3.2%
0.8 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.5% · Q3 3.3% · Q4 2.3% · 4Q avg 2.4% · 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 | 5.4% |
5.6%
0.2 pts better
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 5.7% · Q3 3.8% · Q4 3.8% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.8% |
21.1%
5.3 pts better
|
19.6%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 16.7% · Q3 13.6% · Q4 15.3% · 4Q avg 15.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.3% |
12.0%
0.7 pts better
|
16.7%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 13.1% · Q3 11.3% · Q4 11.6% · 4Q avg 11.3% · 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 | 12.9% |
17.5%
4.6 pts better
|
16.3%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 16.8% · Q3 9.6% · Q4 14.7% · 4Q avg 12.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.3% |
14.7%
4.4 pts better
|
14.9%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 17.3% · Q3 4.9% · Q4 10.0% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.7%
0.5 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.8% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
2.0%
1.1 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.8% |
21.6%
3.2 pts worse
|
19.8%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.1% · Q2 27.3% · Q3 30.0% · Q4 16.8% · 4Q avg 24.8% |
| Percentage of long-stay residents with pressure ulcers | 6.8% |
4.4%
2.4 pts worse
|
5.1%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 8.0% · Q3 7.7% · Q4 5.2% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.2% |
83.5%
8.7 pts better
|
81.7%
10.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.6% · Q2 90.9% · Q3 97.9% · Q4 94.4% · 4Q avg 92.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.5% |
11.2%
12.3 pts worse
|
12.0%
11.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.5% · Observed 25.0% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
0.9%
1.6 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.4% · Q3 3.2% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.8% |
83.1%
11.7 pts better
|
79.7%
15.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.8% |
21.5%
2.3 pts worse
|
23.9%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.8% · Observed 25.0% · Expected 25.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2025-02-04 · Fire 2025-02-04
12 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 2024-07-17 · Fire 2024-07-17
7 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.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-14
D · Potential for more than minimal harm
2025-07-01
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-07-14
E · Potential for more than minimal harm
2025-02-04
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 2025-03-14
E · Potential for more than minimal harm
2025-02-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-14
E · Potential for more than minimal harm
2025-02-04
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2025-03-14
D · Potential for more than minimal harm
2025-02-04
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 2025-03-14
D · Potential for more than minimal harm
2025-02-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-14
D · Potential for more than minimal harm
2025-02-04
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 2025-03-14
D · Potential for more than minimal harm
2025-02-04
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-03-14
D · Potential for more than minimal harm
2025-02-04
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-03-14
G · Actual harm
2024-12-31
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 2024-10-29
E · Potential for more than minimal harm
2024-12-31
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-31
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-10-09
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 2024-10-23
D · Potential for more than minimal harm
2024-07-17
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 2024-08-07
D · Potential for more than minimal harm
2024-07-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-07
J · Immediate jeopardy
2023-12-15
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 2023-06-10
E · Potential for more than minimal harm
2023-12-15
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 2024-01-23
D · Potential for more than minimal harm
2023-12-15
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-08-25
E · Potential for more than minimal harm
2023-05-16
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 2023-06-29
D · Potential for more than minimal harm
2023-05-16
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 2023-06-29
Penalties and ownership
What sits behind the stars
$12,035
2024-12-31
Fine
Fine · fine $12,035
Fine
$65,832
2023-12-15
Fine
Fine · fine $65,832
Fine
$148,604
2023-05-16
Fine
Fine · fine $148,604
Fine
Ownership
Gelley, Leah
5% Or Greater Direct Ownership Interest · Individual
Gelley, Meir
5% Or Greater Direct Ownership Interest · Individual
Gelley, Meir
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Gilpin Hall
Wilmington, DE
3-star overall rating with 2-star inspections with abuse icon flag with 13 recent health deficiencies
#2
Complete Care At Hillside LLC
Wilmington, DE
4-star overall rating with 3-star inspections with 20 recent health deficiencies
#3
Kentmere Rehabilitation And Healthcare Center
Wilmington, DE
3-star overall rating with 2-star inspections with 20 recent health deficiencies
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