Inspection Reports for Wilmington Nursing and Rehabilitation
700 Foulk Road, DE, 19803
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Routine
Deficiencies: 1
May 13, 2025
Visit Reason
The inspection was conducted to review compliance with minimum staffing levels for residential health facilities, specifically focusing on nursing services direct caregiver staffing ratios.
Findings
The facility was found noncompliant with Delaware Code Chapter 11 Nursing Staffing requirements, failing to maintain the required CNA staffing ratios of 1:9 during the day shift and 1:10 during the evening shift for the week of 3/30/25 to 4/5/25. The administrator educated the staff scheduler and implemented audits to ensure compliance.
Deficiencies (1)
| Description |
|---|
| Failure to maintain the CNA ratio of 1:9 on the day shift and 1:10 on the evening shift during the week of 3/30/25-4/5/25. |
Report Facts
Date of compliance: Jun 2, 2025
Inspection Report
Follow-Up
Census: 114
Deficiencies: 5
Dec 23, 2024
Visit Reason
An unannounced Follow Up and Complaint Survey was conducted at Wilmington Nursing & Rehabilitation Center from December 17, 2024, through December 23, 2024, based on observations, interviews, and review of clinical records and other facility documentation.
Findings
The survey identified deficiencies related to resident rights, care planning, pressure ulcer prevention and treatment, infection control, and environmental safety. The facility failed to ensure resident self-determination, proper care plan conferences, adequate pressure ulcer care, and maintenance of a safe environment free of accident hazards.
Complaint Details
The visit was complaint-related as indicated by the combined Follow Up and Complaint Survey. Specific complaint details are not separately stated but deficiencies relate to resident rights, care planning, pressure ulcer care, environmental safety, and infection control.
Severity Breakdown
SS=D: 4
SS=E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to identify and facilitate resident's self-determination through support of resident choice with respect to scheduled shower times. | SS=D |
| Facility failed to schedule and conduct care plan conferences after quarterly MDS assessments. | SS=D |
| Facility failed to provide care to residents with pressure ulcers to promote healing. | SS=D |
| Facility failed to provide an environment free of accident hazards; diabetic lancets were stored in an unlocked cabinet accessible to residents. | SS=D |
| Facility failed to establish and maintain an infection control program; failures included improper use of PPE, lack of staff education, and inadequate isolation precautions. | SS=E |
Report Facts
Facility census: 114
Sample size: 27
Deficiency counts: 5
Date range of survey: December 17, 2024 through December 23, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Renee Boyer | LNHA | Provider's signature and named in exit conferences |
| E1 | NHA | Interviewed and participated in exit conference |
| E2 | DON | Interviewed and participated in exit conference |
| E18 | CNA | Interviewed regarding resident shower schedule |
| E4 | RN/UM | Interviewed regarding resident shower refusal |
| E6 | RN/UM | Interviewed regarding resident shower refusal |
| E19 | SW | Interviewed regarding care plan conferences and medication list |
| E15 | LPN | Interviewed regarding broken lock on staff dining room door |
| E10 | Staff Educator | Interviewed regarding infection control education |
Inspection Report
Annual Inspection
Census: 128
Deficiencies: 14
Oct 2, 2024
Visit Reason
An unannounced Annual and Complaint survey was conducted at Wilmington Nursing & Rehabilitation Center from September 19, 2024 through October 2, 2024. The survey included review of residents' clinical records, observations, interviews, and other facility documentation.
Findings
The facility was found to have multiple deficiencies including failure to provide adequate staffing hours, failure to develop and implement comprehensive care plans, failure to accurately assess and manage pressure ulcers, pain management issues, medication errors, and deficiencies in food safety and resident rights. The facility also failed to ensure proper documentation and follow-up in several areas including hospice care, nutrition, and wound care.
Severity Breakdown
F552: 1
F641: 1
F656: 1
F684: 1
F690: 1
F695: 1
F697: 1
F732: 1
F757: 1
F807: 1
F812: 1
F842: 1
F849: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Failure to provide minimum staffing hours of 3.28 hours of direct care per patient day for fifteen days out of 91 days. | — |
| Failure to inform residents and make treatment decisions in accordance with rights. | F552 |
| Failure to accurately assess and document pressure ulcers and skin conditions. | F641 |
| Failure to develop and implement comprehensive, person-centered care plans for residents. | F656 |
| Failure to develop and implement fall care plans for residents at risk. | F684 |
| Failure to provide adequate bowel and bladder care plans and assessments. | F690 |
| Failure to provide adequate respiratory and tracheostomy care. | F695 |
| Failure to provide adequate pain management for residents with pain. | F697 |
| Failure to post nurse staffing information as required. | F732 |
| Failure to ensure residents are free from unnecessary drugs and medication errors. | F757 |
| Failure to provide adequate food and drink to meet resident needs and preferences. | F807 |
| Failure to ensure food procurement, storage, preparation, and service meet sanitary standards. | F812 |
| Failure to maintain resident rights including confidentiality and medical record retention. | F842 |
| Failure to provide adequate hospice services and coordination with hospice providers. | F849 |
Report Facts
Facility census: 128
Investigative sample: 46
Days below staffing requirement: 15
Braden scale risk score: 13
Weight loss percentage: 11
Episodes of urinary incontinence: 113
Episodes of bowel incontinence: 24
Fall risk score: 16
Fall risk score: 17
Fall risk score: 7
BIMS score: 15
BIMS score: 9
BIMS score: 2
BIMS score: 10
BIMS score: 11
BIMS score: 18
BIMS score: 14.7
Weight: 96.6
Weight loss percentage: 11
Medication errors: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Renee Boyer | NHA | Named as Nursing Home Administrator signing the report |
Inspection Report
Annual Inspection
Deficiencies: 4
Oct 2, 2024
Visit Reason
The inspection was conducted as a standard annual survey of Wilmington Nursing & Rehabilitation Center to assess compliance with federal regulations including infection control, immunizations, and environmental safety.
Findings
The facility was found deficient in several areas including infection prevention and control, influenza and pneumococcal immunizations, COVID-19 immunization policies, and maintaining a safe, sanitary, and comfortable environment. Specific issues included failure to implement enhanced barrier precautions, lack of PPE use during wound care, incomplete immunization education and documentation, and improper trash disposal.
Severity Breakdown
SS=E: 2
SS=D: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to establish and maintain an infection prevention and control program using enhanced barrier precautions for residents with indwelling feeding tubes and chronic wounds. | SS=E |
| Failure to provide influenza and pneumococcal immunizations education and documentation for residents. | SS=D |
| Failure to develop and implement COVID-19 immunization policies ensuring residents and staff are offered vaccines and educated on benefits and risks. | SS=E |
| Failure to provide a safe, sanitary, and comfortable environment as evidenced by trash dumpsters with open lids, contaminated trash bags, and soiled resident briefs and used PPE on the ground. | SS=D |
Report Facts
Residents reviewed for infection control: 4
Residents sampled for influenza and pneumococcal vaccinations: 5
Residents sampled for COVID-19 vaccinations: 5
Date of completion for corrective actions: 11/18/2024
Inspection Report
Follow-Up
Census: 117
Deficiencies: 2
Jun 3, 2024
Visit Reason
An unannounced Follow-Up Survey to the Complaint and Extended Survey ending April 10, 2024 was conducted from May 30, 2024 through June 3, 2024 to verify correction of previous deficiencies.
Findings
The facility was found deficient in scheduling timely follow-up eye care appointments and in preventing and treating pressure ulcers. Root cause analyses identified failures in admission appointment scheduling and skin check observation processes. The facility implemented new processes and education to address these issues, with compliance monitoring planned.
Complaint Details
This was a follow-up survey to a complaint and extended survey ending April 10, 2024. The deficiencies relate to the complaint investigation.
Severity Breakdown
Level D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure timely follow-up eye physician appointment for resident R9. | Level D |
| Failure to provide treatment and monitoring to prevent and heal pressure ulcers for resident R10. | Level D |
Report Facts
Facility census: 117
Sample size: 10
Survey period: 5
Days pressure ulcer treatment not documented: 51
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Renee Boyer | LNHA | Provider's signature on report |
| E13 | Unit Clerk | Confirmed lack of ophthalmology appointment scheduling for resident R9 |
| E4 | Medical Director | Ordered ophthalmology appointment for resident R9 |
| E3 | ADON | Confirmed physician order for ophthalmology appointment for resident R9 |
| E1 | NHA | Findings reviewed with |
| E2 | DON | Findings reviewed with |
| E12 | RDCS | Findings reviewed with |
| E14 | VPO | Findings reviewed with |
| R6 | LPN | Interviewed regarding weekly skin checks |
| E7 | LPN | Interviewed regarding weekly skin checks and wound care |
Inspection Report
Complaint Investigation
Census: 123
Deficiencies: 5
Apr 10, 2024
Visit Reason
An unannounced complaint and extended survey was conducted from April 5, 2024 through April 10, 2024 to investigate deficiencies based on observations, interviews, and record reviews related to resident injuries and reporting.
Findings
The facility was found to be in substantial compliance with federal requirements but failed to report injuries of unknown origin within required timeframes and failed to ensure proper notification and documentation of resident falls and injuries. Deficiencies included failure to notify the State Agency within 8 hours of an injury, failure to notify and document post-fall assessments timely, and failure to update the facility assessment and governing body documents.
Complaint Details
The visit was triggered by a complaint regarding failure to report injuries and falls timely and failure to provide appropriate follow-up care and documentation. The complaint was substantiated based on findings of delayed reporting and inadequate documentation.
Severity Breakdown
C: 1
D: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to report injuries of unknown origin (bruises) to the State Agency within the required 8 hour timeframe. | D |
| Failure to notify and document post-fall assessments timely and accurately in the medical record. | D |
| Failure to update the facility assessment to include all personnel classifications and failure to update governing body documents to reflect current members. | C |
| Failure to ensure resident R3's fall was reported to the State Agency as required. | D |
| Failure to ensure bladder scan orders and documentation were accurate and timely for resident R2. | D |
Report Facts
Facility census: 123
Sample size: 6
Date range of survey: April 5, 2024 through April 10, 2024
Date of correction: Multiple deficiencies have correction dates of 5/13/2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Renee Boyer | LNHA | Provider signature on report |
| E1 | NHA | Director of Nursing involved in exit conferences and education |
| E2 | DON | Director of Nursing involved in exit conferences and education |
| E3 | RN RDCS | Regional Director of Clinical Services involved in exit conferences |
| E15 | LPN | Licensed Practical Nurse who observed resident bruises and failed to report |
| E19 | Nurse | Educated by Director of Nursing on documenting post fall assessments |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 0
Feb 1, 2024
Visit Reason
An unannounced complaint survey was conducted at the facility from January 29, 2024 through February 1, 2024.
Findings
No deficiencies were identified at the time of the survey or as a result of the complaint visit.
Complaint Details
The complaint investigation found no deficiencies and no substantiated issues.
Report Facts
Survey duration days: 4
Facility census: 92
Inspection Report
Follow-Up
Census: 92
Deficiencies: 0
Jan 31, 2024
Visit Reason
An unannounced third Follow-Up Survey was conducted from January 29, 2024 through January 31, 2024, following previous surveys including the Annual, Complaint, Emergency Preparedness Survey ending July 31, 2023, an Extended Survey ending August 10, 2023, the first Follow-Up Survey ending November 7, 2023, and the second Follow-Up Survey ending January 8, 2024.
Findings
No deficient practices were identified during this third Follow-Up Survey. The facility was found to have regained substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities as of January 31, 2024.
Report Facts
Sample size: 6
Inspection Report
Annual Inspection
Census: 136
Deficiencies: 10
Aug 10, 2023
Visit Reason
An unannounced Annual, Complaint and Emergency Preparedness Survey was conducted from July 13, 2023 through July 31, 2023, with an Extended Survey also conducted from August 9, 2023 through August 10, 2023. The survey was based on observations, interviews, review of residents' clinical records and review of facility documentation.
Findings
The report details multiple deficiencies related to residents' rights, personnel screening, nursing staffing, medication administration, resident care, abuse prevention, grievance handling, and quality of care. The facility failed to meet several regulatory requirements including tuberculosis screening, drug testing, adult abuse registry checks, and adequate staffing levels. Numerous clinical record reviews revealed failures in care planning, treatment, and monitoring of residents.
Deficiencies (10)
| Description |
|---|
| Failure to conduct mandatory tuberculosis screening for employees. |
| Failure to conduct mandatory drug testing and adult abuse registry checks for personnel. |
| Failure to maintain minimum staffing levels to provide adequate care. |
| Failure to provide immediate access to residents by authorized representatives. |
| Failure to ensure residents' rights to privacy and grievance procedures. |
| Failure to prevent abuse and neglect, including failure to investigate and report incidents. |
| Failure to develop and implement comprehensive care plans addressing residents' needs. |
| Failure to provide adequate supervision and care to prevent injuries and manage behaviors. |
| Failure to provide adequate skin care and prevent pressure ulcers. |
| Failure to ensure proper medication administration and monitoring. |
Report Facts
Facility census: 136
Survey period: 19
Extended survey period: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Renee Boyer | NHA | Administrator named in relation to findings and plan of correction |
Inspection Report
Annual Inspection
Census: 132
Deficiencies: 12
Aug 10, 2023
Visit Reason
The inspection was conducted as an annual survey of Promedica Skilled Nursing and Rehab - Wilmington to assess compliance with federal regulations and evaluate the quality of care provided to residents.
Findings
The facility was found deficient in multiple areas including accident prevention, supervision of residents with aggressive behaviors, bowel and bladder care, nutrition and hydration, pain management, medication regimen review, infection prevention and control, staff training, and resident rights. Several corrective actions and plans of correction were implemented with completion dates mostly by 9/25/2023.
Deficiencies (12)
| Description |
|---|
| Facility failed to ensure adequate supervision and assistance to prevent accidents for residents with aggressive behaviors. |
| Facility failed to ensure residents received appropriate bowel and bladder care and assessments. |
| Facility failed to ensure adequate nutrition and hydration for residents, including monitoring fluid intake and providing sufficient fluids. |
| Facility failed to provide adequate pain management and assessment for residents. |
| Facility failed to provide adequate medication regimen review and timely administration of medications. |
| Facility failed to maintain infection prevention and control program, including surveillance and staff training. |
| Facility failed to provide adequate staffing and supervision to ensure resident safety and medication administration. |
| Facility failed to provide required training for staff on resident rights, abuse prevention, behavioral health, compliance and ethics, and other mandatory trainings. |
| Facility failed to ensure adequate food safety and sanitation in kitchen and food service areas. |
| Facility failed to ensure residents received appropriate respiratory and tracheostomy care. |
| Facility failed to ensure adequate ventilation in the Arcadia unit. |
| Facility failed to ensure sufficient nursing staff with appropriate competencies and skills. |
Report Facts
Residents present: 132
Deficiency completion dates: 9
Fluid intake days reviewed: 23
Medication administration times: 3
Staff training completion: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E26 | Rehab Director | Interviewed regarding resident bed mobility and transfer status |
| E1 | NHA (Nursing Home Administrator) | Participated in exit conference and review of findings |
| E2 | DON (Director of Nursing) | Participated in exit conference, involved in audits and corrective actions |
| E4 | RCD (Resident Care Director) | Participated in exit conference and review of findings |
| E18 | VPO (Vice President of Operations) | Participated in exit conference and review of findings |
| E53 | Staff Development Nurse | Educated staff on abuse, neglect, compliance, and resident rights training |
| E40 | RN/Staff Development | Confirmed IP role and participated in audits |
| E24 | ADON (Assistant Director of Nursing) | Interviewed about bladder and bowel assessments |
| E56 | Dietician | Interviewed regarding hydration and nutrition assessments |
| E66 | LPN | Observed performing hand hygiene and oxygen therapy education |
| E16 | HRD (Human Resources Director) | Interviewed regarding staff training and compliance |
| E3 | ADON | Participated in exit conference and review of findings |
| E21 | RN MDS Coordinator | Interviewed about MDS assessments and documentation |
Inspection Report
Complaint Investigation
Census: 126
Deficiencies: 0
Jun 28, 2022
Visit Reason
An unannounced complaint survey was conducted regarding food services, kitchen sanitation, and pest management.
Findings
No deficiencies were identified during the survey.
Complaint Details
The complaint was about food services, kitchen sanitation, and pest management. The survey found no deficiencies.
Report Facts
Facility census: 126
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