Cycle 1
Health 2024-10-02 · Fire 2024-10-02
27 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Wilmington, DE
Wilmington Nursing & Rehabilitation Center
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
700 Foulk Road, Wilmington, DE
(302) 764-0181
Overall
1 / 5
CMS overall stars
Health inspections
1 / 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
138
Certified beds
Average residents
116
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lifeworks Rehab
Operator or chain grouping
Approved since
1984-07-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
59 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 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
0.65
Registered nurse staffing · state 1.03 · national 0.68
LPN hours / resident day
1.18
Licensed practical nurse staffing · state 1.01 · national 0.87
Aide hours / resident day
2.08
Nurse aide staffing · state 2.47 · national 2.35
Total nurse hours
3.90
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.83
RN + LPN hours · state 2.04 · national 1.54
Weekend hours
3.39
Weekend nurse staffing · state 4.04 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.72 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.15 · national 0.07
Adjusted RN hours
0.67
CMS adjusted RN staffing hours
Adjusted total hours
4.04
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
26%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,424
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.42
Composite VBP score used to determine payment impact.
Payment multiplier
0.9824
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.83
Baseline 18.94% · Performance 20.12% · Measure score 2.83 · Achievement 2.83 · Improvement 0
Healthcare-associated infections
1.45
Baseline 4.81% · Performance 7.40% · Measure score 1.45 · Achievement 1.45 · Improvement 0
Total nurse turnover
0
Baseline 34.62% · Performance 64.19% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.89
Baseline 3.75 hours · Performance 4.18 hours · Measure score 3.89 · Achievement 3.89 · Improvement 1.62
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.6% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 273 · Observed rate 7.33% · Lower 95% interval 6.66% |
| Discharge to community | 60.55% |
50.57%
10 pts better
|
Better than the National Rate · Eligible stays 273 · Observed rate 56.04% · Lower 95% interval 54.49% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.91% |
95.27%
3.6 pts better
|
Numerator 182 · Denominator 184 |
| Falls with major injury | 0.54% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 184 |
| Discharge self-care score | 73.08% |
53.69%
19.4 pts better
|
Numerator 95 · Denominator 130 |
| Discharge mobility score | 66.92% |
50.94%
16 pts better
|
Numerator 87 · Denominator 130 |
| Pressure ulcers or injuries, new or worsened | 5.46% |
2.29%
3.2 pts worse
|
Numerator 10 · Denominator 183 · Adjusted rate 5.39% |
| Healthcare-associated infections requiring hospitalization | 7.4% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 137 · Observed rate 7.3% · Lower 95% interval 4.75% |
| Staff COVID-19 vaccination coverage | 1.16% |
8.2%
7 pts worse
|
Numerator 2 · Denominator 173 |
| Staff flu vaccination coverage | 33.71% |
42%
8.3 pts worse
|
Numerator 59 · Denominator 175 |
| Discharge function score | 68.46% |
56.45%
12 pts better
|
Numerator 89 · Denominator 130 |
| Transfer of health information to provider | 90% |
95.95%
6 pts worse
|
Numerator 63 · Denominator 70 |
| Transfer of health information to patient | 96.15% |
96.28%
0.1 pts worse
|
Numerator 75 · Denominator 78 |
| Resident COVID-19 vaccinations up to date | 31.25% |
25.2%
6.1 pts better
|
Numerator 30 · Denominator 96 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.8
About the same
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.6 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
1.4
1.2 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.0 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.9% |
95.7%
0.2 pts better
|
93.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.7% · Q2 97.9% · Q3 97.3% · Q4 94.9% · 4Q avg 95.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.4% |
97.4%
10 pts worse
|
95.5%
8.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 87.4% |
| 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 3.2% · Q2 3.2% · Q3 5.3% · Q4 6.3% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.1% |
6.5%
3.6 pts worse
|
11.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 6.2% · Q3 11.8% · Q4 11.0% · 4Q avg 10.1% |
| Percentage of long-stay residents who lose too much weight | 10.0% |
5.6%
4.4 pts worse
|
5.4%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 11.2% · Q3 10.4% · Q4 8.2% · 4Q avg 10.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 35.6% |
21.1%
14.5 pts worse
|
19.6%
16 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 34.9% · Q3 40.0% · Q4 40.5% · 4Q avg 35.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.9% |
12.0%
6.9 pts worse
|
16.7%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 15.4% · Q3 17.9% · Q4 21.3% · 4Q avg 18.9% · 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 | 12.8% |
17.5%
4.7 pts better
|
16.3%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 15.5% · Q3 12.4% · Q4 3.1% · 4Q avg 12.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.7% |
14.7%
3 pts worse
|
14.9%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 16.5% · Q3 26.5% · Q4 10.1% · 4Q avg 17.7% · 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 0.8% · Q3 0.0% · Q4 0.0% · 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 0.0% · Q2 2.2% · Q3 0.0% · Q4 1.3% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.4% |
21.6%
6.8 pts worse
|
19.8%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 32.6% · Q3 32.5% · Q4 25.6% · 4Q avg 28.4% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
4.4%
1.8 pts worse
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 6.4% · Q3 5.8% · Q4 4.6% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.6% |
83.5%
1.9 pts worse
|
81.7%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 62.0% · Q2 77.7% · Q3 92.8% · Q4 90.6% · 4Q avg 81.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.2% |
11.2%
1 pts worse
|
12.0%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.2% · Observed 12.1% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
0.9%
0.3 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.5% |
83.1%
0.4 pts better
|
79.7%
3.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.1% |
21.5%
4.6 pts worse
|
23.9%
2.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.1% · Observed 25.4% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-10 · Fire 2023-08-10
48 health deficiencies
Top issue: Quality of Life and Care (14 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2019-11-25 · Fire 2019-11-25
10 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (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
2024-10-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-31
E · Potential for more than minimal harm
2024-10-02
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-10-31
E · Potential for more than minimal harm
2024-10-02
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-31
F · Potential for more than minimal harm
2023-08-10
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-09-11
F · Potential for more than minimal harm
2023-08-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-09-11
E · Potential for more than minimal harm
2023-08-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-09-11
E · Potential for more than minimal harm
2023-08-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-11
E · Potential for more than minimal harm
2023-08-10
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-09-11
E · Potential for more than minimal harm
2023-08-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-09-11
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-09
D · Potential for more than minimal harm
2025-12-04
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2026-01-09
D · Potential for more than minimal harm
2025-12-04
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2026-01-09
D · Potential for more than minimal harm
2025-12-04
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2026-01-09
D · Potential for more than minimal harm
2025-12-04
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2026-01-09
G · Actual harm
2024-10-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-15
G · Actual harm
2024-10-02
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-11-18
F · Potential for more than minimal harm
2024-10-02
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 2024-11-18
E · Potential for more than minimal harm
2024-10-02
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 2024-11-18
E · Potential for more than minimal harm
2024-10-02
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 2025-01-15
E · Potential for more than minimal harm
2024-10-02
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 2024-11-18
E · Potential for more than minimal harm
2024-10-02
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-11-18
E · Potential for more than minimal harm
2024-10-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-15
E · Potential for more than minimal harm
2024-10-02
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-10-02
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-10-02
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 2025-01-15
D · Potential for more than minimal harm
2024-10-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-10-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-10-02
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 2024-11-18
D · Potential for more than minimal harm
2024-10-02
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 2025-01-15
D · Potential for more than minimal harm
2024-10-02
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-10-02
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-10-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-10-02
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-10-02
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-10-02
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-10-02
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-10-02
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-10-02
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-11-18
B · Minimal harm
2024-10-02
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 2024-11-18
J · Immediate jeopardy
2024-04-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-26
D · Potential for more than minimal harm
2024-04-10
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 2024-05-13
D · Potential for more than minimal harm
2024-04-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-06-26
D · Potential for more than minimal harm
2024-04-10
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 2024-05-13
D · Potential for more than minimal harm
2024-04-10
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 2024-05-13
C · Minimal harm
2024-04-10
F837 · Administration Deficiencies
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2024-05-13
K · Immediate jeopardy
2023-08-10
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-09-25
K · Immediate jeopardy
2023-08-10
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-09-25
J · Immediate jeopardy
2023-08-10
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2023-12-06
J · Immediate jeopardy
2023-08-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-12-06
G · Actual harm
2023-08-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-25
G · Actual harm
2023-08-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-09-25
F · Potential for more than minimal harm
2023-08-10
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 2023-09-25
F · Potential for more than minimal harm
2023-08-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-06
F · Potential for more than minimal harm
2023-08-10
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-09-25
E · Potential for more than minimal harm
2023-08-10
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 2023-12-06
E · Potential for more than minimal harm
2023-08-10
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-12-06
E · Potential for more than minimal harm
2023-08-10
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 2023-09-25
E · Potential for more than minimal harm
2023-08-10
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 2023-09-25
E · Potential for more than minimal harm
2023-08-10
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 2023-12-06
E · Potential for more than minimal harm
2023-08-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-06
E · Potential for more than minimal harm
2023-08-10
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 2023-09-25
E · Potential for more than minimal harm
2023-08-10
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-09-25
E · Potential for more than minimal harm
2023-08-10
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 2023-09-25
E · Potential for more than minimal harm
2023-08-10
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-09-25
E · Potential for more than minimal harm
2023-08-10
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 2023-09-25
D · Potential for more than minimal harm
2023-08-10
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 2023-12-06
D · Potential for more than minimal harm
2023-08-10
F562 · Resident Rights Deficiencies
Health
Provide immediate access to any resident.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-08-10
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 2023-09-25
D · Potential for more than minimal harm
2023-08-10
F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2022-12-01
D · Potential for more than minimal harm
2023-08-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-08-10
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 2023-12-06
D · Potential for more than minimal harm
2023-08-10
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 2023-09-25
D · Potential for more than minimal harm
2023-08-10
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 2023-12-06
D · Potential for more than minimal harm
2023-08-10
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-08-10
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 2023-12-06
D · Potential for more than minimal harm
2023-08-10
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 2023-12-06
D · Potential for more than minimal harm
2023-08-10
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-08-10
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-08-10
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 2023-12-06
D · Potential for more than minimal harm
2023-08-10
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-01-31
D · Potential for more than minimal harm
2023-08-10
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 2023-12-06
D · Potential for more than minimal harm
2023-08-10
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 2023-09-25
D · Potential for more than minimal harm
2023-08-10
F923 · Environmental Deficiencies
Health
Have enough outside ventilation via a window or mechanical ventilation, or both.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-08-10
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-08-10
F942 · Resident Rights Deficiencies
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-08-10
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 2023-12-06
D · Potential for more than minimal harm
2023-08-10
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-08-10
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-08-10
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2023-09-25
E · Potential for more than minimal harm
2019-11-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-01-21
D · Potential for more than minimal harm
2019-11-25
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 2020-01-21
D · Potential for more than minimal harm
2019-11-25
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2020-01-21
D · Potential for more than minimal harm
2019-11-25
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2020-01-21
D · Potential for more than minimal harm
2019-11-25
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 2020-01-21
Penalties and ownership
What sits behind the stars
$212,076
2024-10-02
Fine
Fine · fine $212,076
Fine
$0
2024-10-02
Payment Denial
Payment Denial · denial start 2024-12-08 · 38 days
38 day denial
$20,071
2024-04-10
Fine
Fine · fine $20,071
Fine
$0
2024-04-10
Payment Denial
Payment Denial · denial start 2024-05-14 · 43 days
43 day denial
$176,595
2023-08-10
Fine
Fine · fine $176,595
Fine
$0
2023-08-10
Payment Denial
Payment Denial · denial start 2023-10-06 · 117 days
117 day denial
Ownership
Wilmington SNF Operator Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Boyer, Renee
W-2 Managing Employee · Individual
Glen Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Highland De Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Ib Mimi 2022 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
J & R Family Investments, LLC
5% Or Greater Indirect Ownership Interest · Organization
Jk 2022 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Landau Family Investment Trust
5% Or Greater Indirect Ownership Interest · Organization
Mimi Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Ml Milano 2022 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Panther De Partners LLC
5% Or Greater Indirect Ownership Interest · Organization
Rajchenbach, Moshe
Corporate Officer · Individual
Vh Wpc SNF Operations Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Wpc SNF Operations Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Encore At Windsor Hills
Wilmington, DE
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
#2
Cadia Rehabilitation Silverside
Wilmington, DE
4-star overall rating with 2-star inspections with abuse icon flag with $10,608 in total fines with 16 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Encore At Wilmington
Wilmington, DE
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
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