Inspection Reports for
Wilmington Nursing and Rehabilitation
700 Foulk Road, Wilmington, DE, 19803
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
29.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
234% worse than Delaware average
Delaware average: 8.8 deficiencies/year
Deficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
83% occupied
Based on a December 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Dec 4, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding failure to provide timely admission orders, inadequate documentation of urostomy and pelvic drain care, failure to maintain adequate nutrition and hydration, untimely completion of ordered laboratory tests, and deficiencies in infection prevention and control practices.
Complaint Details
The visit was complaint-related, investigating allegations of failure to provide timely admission orders, inadequate documentation of urostomy and pelvic drain care, failure to maintain nutrition and hydration, untimely lab testing, and infection control deficiencies. Findings were substantiated as described in the deficiencies.
Findings
The facility failed to ensure timely admission orders for wound care, proper documentation of urostomy and pelvic drain output, maintenance of adequate nutrition and hydration for residents, timely completion of laboratory tests, and implementation of infection prevention protocols including Enhanced Barrier Precautions and safe sharps disposal.
Deficiencies (5)
F0635: The facility failed to provide doctor's orders for wound treatment at the time of resident R150's admission, with orders entered two days after admission.
F0691: The facility failed to document urostomy and pelvic drain output as ordered for resident R149, with multiple missing entries in the treatment administration record.
F0692: The facility failed to maintain adequate nutrition and hydration for residents R11 and R143, including failure to monitor weight changes and document fluid intake as required.
F0770: The facility failed to ensure ordered laboratory tests for resident R149 were completed timely, with delays in collecting urinalysis samples.
F0880: The facility failed to implement infection prevention and control measures, including failure to maintain Enhanced Barrier Precautions for residents with wounds and indwelling devices and failure to safely dispose of a full sharps container.
Report Facts
Weight loss percentage: 23.3
Dates with missing urostomy drainage documentation: 7
Dates with missing pelvic drain documentation: 4
Missed fluid intake documentation shifts for resident R143: 17
Missed fluid intake documentation shifts for resident R143: 22
Missed fluid intake documentation shifts for resident R143: 24
Missed fluid intake documentation shifts for resident R143: 13
Missed fluid intake documentation shifts for resident R143: 16
Missed fluid intake documentation shifts for resident R143: 16
Missed fluid intake documentation shifts for resident R143: 11
Missed fluid intake documentation shifts for resident R143: 3
Missed fluid intake documentation shifts for resident R143: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E14 | Registered Nurse (RN) | Named in wound care order deficiency for resident R150. |
| E40 | Licensed Practical Nurse (LPN) | Confirmed findings regarding missing urostomy and pelvic drain documentation for resident R149. |
| E2 | Director of Nursing (DON) | Confirmed missing weight monitoring and nutrition documentation for resident R11. |
| E34 | Registered Dietitian (RD) | Conducted nutrition assessments for resident R11. |
| E41 | Registered Nurse (RN), Unit Manager | Confirmed untimely lab collection for resident R149. |
| E26 | Licensed Practical Nurse (LPN) | Interviewed regarding infection control practices for resident R35. |
| E32 | Certified Nursing Assistant (CNA) | Interviewed regarding infection control practices and disinfectant use. |
| E39 | Licensed Practical Nurse (LPN), Unit Manager | Confirmed full sharps container and replacement procedures. |
| E5 | Licensed Practical Nurse (LPN), Unit Manager | Confirmed full sharps container and replaced it. |
| E11 | Infection Preventionist (IP) | Confirmed Enhanced Barrier Precautions should be in place for residents with chronic wounds. |
Inspection Report
Routine
Deficiencies: 1
Date: 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)
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
Date: 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.
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.
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.
Deficiencies (5)
Facility failed to identify and facilitate resident's self-determination through support of resident choice with respect to scheduled shower times.
Facility failed to schedule and conduct care plan conferences after quarterly MDS assessments.
Facility failed to provide care to residents with pressure ulcers to promote healing.
Facility failed to provide an environment free of accident hazards; diabetic lancets were stored in an unlocked cabinet accessible to residents.
Facility failed to establish and maintain an infection control program; failures included improper use of PPE, lack of staff education, and inadequate isolation precautions.
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
Deficiencies: 11
Date: Oct 2, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to support resident self-determination, inadequate care plan revisions, improper treatment and monitoring of residents, medication errors, insufficient supervision to prevent accidents, inadequate nutrition and hydration management, and unsafe environmental conditions.
Deficiencies (11)
F 0561: The facility failed to honor resident R76's right to self-determination by not facilitating his choice regarding scheduled shower times, resulting in missed showers without documented refusals.
F 0657: The facility failed to review and revise care plans for residents R116 and R26 to reflect current needs, including continence and hospice care plans.
F 0684: The facility failed to provide appropriate treatment and monitoring for resident R127's orthostatic hypotension and failed to ensure follow-up nephrology appointments for R116.
F 0686: The facility failed to provide adequate pressure ulcer care for residents R26, R105, R228, and R533, including failure to stage ulcers, implement turning and repositioning, complete skin audits, and collaborate with hospice.
F 0689: The facility failed to provide adequate supervision to prevent a fall for resident R64, resulting in a fall and hospital transfer.
F 0692: The facility failed to maintain acceptable nutritional parameters for resident R83, including delayed ordering of nutritional supplements and inadequate weight monitoring.
F 0757: The facility failed to monitor and hold blood pressure medication for resident R116 according to physician orders, resulting in administration despite low blood pressure readings.
F 0760: The facility failed to prevent a significant medication error for resident R116 by administering Metformin and Ibuprofen concurrently despite pharmacy warnings, contributing to acute kidney injury and hospitalization.
F 0807: The facility failed to order and provide an Ensure nutritional supplement for resident R116 in a timely manner based on dietary recommendations and resident preference.
F 0842: The facility failed to maintain accurate and complete clinical records for residents R6, R26, and R116, including repeated inaccurate progress notes and undocumented care.
F 0921: The facility failed to maintain a safe and sanitary environment by allowing soiled resident briefs and used PPE gloves to accumulate around outdoor trash dumpsters.
Report Facts
Weight loss: 11
Creatinine level: 4.2
BUN level: 87
Pressure ulcer size: 4.2
Pressure ulcer size: 6.5
Pressure ulcer size: 0.2
Fall risk score: 7
Fall risk score: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E4 | Medical Director | Named in findings related to orthostatic vital signs and medication management for R127 and R116. |
| E13 | Dietician | Named in findings related to nutrition assessment and recommendations for R83 and R116. |
| E50 | Nurse Practitioner | Named in findings related to inaccurate progress notes and medication management for R26 and R116. |
| E1 | Nursing Home Administrator | Participated in exit conferences and confirmed environmental and supervision findings. |
| E2 | Director of Nursing | Participated in exit conferences and confirmed supervision and documentation findings. |
| E3 | Assistant Director of Nursing | Participated in exit conferences. |
| E46 | VPO | Participated in exit conferences. |
Inspection Report
Annual Inspection
Census: 128
Deficiencies: 14
Date: 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.
Deficiencies (14)
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.
Failure to accurately assess and document pressure ulcers and skin conditions.
Failure to develop and implement comprehensive, person-centered care plans for residents.
Failure to develop and implement fall care plans for residents at risk.
Failure to provide adequate bowel and bladder care plans and assessments.
Failure to provide adequate respiratory and tracheostomy care.
Failure to provide adequate pain management for residents with pain.
Failure to post nurse staffing information as required.
Failure to ensure residents are free from unnecessary drugs and medication errors.
Failure to provide adequate food and drink to meet resident needs and preferences.
Failure to ensure food procurement, storage, preparation, and service meet sanitary standards.
Failure to maintain resident rights including confidentiality and medical record retention.
Failure to provide adequate hospice services and coordination with hospice providers.
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
Routine
Deficiencies: 16
Date: Oct 2, 2024
Visit Reason
Routine inspection of Wilmington Nursing & Rehabilitation Center to assess compliance with healthcare regulations including resident care, safety, infection control, and medication management.
Findings
The facility had multiple deficiencies including failure to provide informed consent for treatment, inadequate resident self-determination support, inaccurate assessments, incomplete care plans, improper medication and treatment administration, insufficient infection control practices, and failure to maintain accurate clinical documentation.
Deficiencies (16)
F0552: The facility failed to provide resident R118 the right to be informed of and participate in her treatment regarding her DMOST form and resuscitation preferences.
F0561: The facility failed to identify and facilitate resident R76's self-determination through support of resident choice regarding scheduled shower times.
F0641: The facility failed to accurately reflect resident R26's sacral skin condition as a Stage 3 pressure ulcer in the annual MDS assessment.
F0656: The facility failed to develop and implement comprehensive person-centered care plans for six residents, including bladder and fall care plans.
F0657: The facility failed to review and revise care plans for residents R116 and R26, including continence and hospice care plans.
F0684: The facility failed to provide appropriate treatment and care according to orders and resident preferences, including failure to obtain orthostatic vital signs as ordered for R127 and failure to schedule follow-up appointments for R116.
F0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for residents R26, R105, R228, and R533, including failure to stage pressure ulcers, implement turning and repositioning, complete skin audits, and collaborate with hospice.
F0688: The facility failed to provide safe and appropriate respiratory care for resident R3 by not administering oxygen therapy as ordered.
F0697: The facility failed to provide safe, appropriate pain management for resident R26 during wound care consistent with her care plan.
F0732: The facility failed to post the required federal nurse staffing information in a conspicuous area accessible to residents and visitors.
F0757: The facility failed to ensure each resident's drug regimen was free from unnecessary drugs and failed to monitor and hold blood pressure medication for resident R116 based on physician ordered parameters.
F0812: The facility failed to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards, including issues with food safety and refrigerator temperatures.
F0842: The facility failed to safeguard resident-identifiable information and maintain complete and accurate medical records for residents R6, R26, and R116.
F0849: The facility failed to arrange for provision of hospice services or assist resident R26 in transferring to a facility that will arrange hospice services, including failure to collaborate with hospice and maintain current hospice documentation.
F0880: The facility failed to provide and implement an infection prevention and control program using enhanced barrier precautions for residents with wounds or indwelling devices.
F0883: The facility failed to educate residents and staff on COVID-19 vaccination, offer the vaccine to eligible residents and staff after education, and properly document vaccination status for residents R9, R30, R53, and R76.
Report Facts
Fall risk score: 18
Episodes of urinary incontinence: 113
Episodes of bowel incontinence: 24
Episodes of urinary incontinence: 74
Episodes of urinary incontinence: 28
Episodes of bowel incontinence: 12
Weight: 96.6
Weight loss percentage: 11
Walk-in freezer temperature: 27
Fall risk score: 7
Fall risk score: 17
Fall risk score: 16
Fall risk score: 18
Braden scale score: 13
Braden scale score: 14
Braden scale score: 7
Braden scale score: 10
Braden scale score: 15
Braden scale score: 15
Braden scale score: 11
Braden scale score: 2
Braden scale score: 17
Braden scale score: 18
Medication administration count: 3
Medication administration count: 4
Medication administration count: 2
Inspection Report
Annual Inspection
Deficiencies: 4
Date: 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.
Deficiencies (4)
Failure to establish and maintain an infection prevention and control program using enhanced barrier precautions for residents with indwelling feeding tubes and chronic wounds.
Failure to provide influenza and pneumococcal immunizations education and documentation for residents.
Failure to develop and implement COVID-19 immunization policies ensuring residents and staff are offered vaccines and educated on benefits and risks.
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.
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
Date: 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.
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.
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.
Deficiencies (2)
Failure to ensure timely follow-up eye physician appointment for resident R9.
Failure to provide treatment and monitoring to prevent and heal pressure ulcers for resident R10.
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
Date: 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.
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.
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.
Deficiencies (5)
Failure to report injuries of unknown origin (bruises) to the State Agency within the required 8 hour timeframe.
Failure to notify and document post-fall assessments timely and accurately in the medical record.
Failure to update the facility assessment to include all personnel classifications and failure to update governing body documents to reflect current members.
Failure to ensure resident R3's fall was reported to the State Agency as required.
Failure to ensure bladder scan orders and documentation were accurate and timely for resident R2.
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
Deficiencies: 6
Date: Apr 10, 2024
Visit Reason
The inspection was conducted due to complaints and incidents involving resident safety, including a resident being sent to the wrong medical appointment, failure to notify providers of resident injuries, and inadequate care related to pressure ulcers and bladder management.
Complaint Details
The complaint investigation was triggered by incidents including a resident being sent to the wrong cardiology appointment, failure to notify providers of injuries, and inadequate care for pressure ulcers and bladder management. The Immediate Jeopardy was declared on 2024-04-08 and abated on 2024-04-10.
Findings
The facility failed to ensure correct resident identification for medical appointments, resulting in an Immediate Jeopardy event. Additionally, the facility failed to notify providers of resident injuries, provide appropriate pressure ulcer care, and properly implement physician-ordered bladder scanning. The facility also failed to update governing body documents and the facility assessment to include all personnel classifications.
Deficiencies (6)
F0580: The facility failed to notify and update the provider of changes to a resident's condition after a fall, missing critical information about injuries and medication.
F0684: The facility sent the wrong resident to a cardiology appointment, resulting in an Immediate Jeopardy due to risk of serious adverse outcomes. The facility also failed to report injuries of unknown origin and ensure proper nursing assessments after a resident's fall.
F0686: The facility failed to initiate treatment and monitoring for a sacral pressure ulcer on a resident readmitted with the condition, lacking documentation and wound care for 51 days.
F0690: The facility failed to ensure appropriate bladder scanning and catheterization for a resident with urinary retention, resulting in a urinary tract infection and inconsistent documentation.
F0837: The facility failed to update governing body documents to remove a former employee's name who was no longer employed by the facility.
F0838: The facility failed to update the facility assessment to include all personnel classifications, specifically omitting Non-Certified Nursing Assistants who provide resident services.
Report Facts
Days without wound care treatment: 51
Bladder scan documentation gaps: 4
Bladder scan documentation gaps: 1
BIMS score: 3
BIMS score: 14
Blood pressure readings: 85
Blood pressure readings: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E5 | Unit Clerk | Named in resident mix-up leading to Immediate Jeopardy |
| E6 | TNA | Escorted wrong resident to cardiology appointment |
| E7 | LPN | Nurse involved in resident mix-up and failure to clarify appointment details |
| E1 | NHA | Administrator involved in incident response and exit conference |
| E2 | DON | Director of Nursing involved in incident response and exit conference |
| E3 | RN RDCS | Registered Nurse involved in incident response and exit conference |
| E16 | CNA | Documented failure to report resident injury |
| E18 | RN | Documented resident injury and incident report |
| C1 | PA | Cardiology Physician Assistant involved in resident mix-up incident |
| E13 | Nurse | Interviewed regarding bladder scan training and documentation |
| E12 | MD | Physician who acknowledged confusing bladder scan order |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 0
Date: Feb 1, 2024
Visit Reason
An unannounced complaint survey was conducted at the facility from January 29, 2024 through February 1, 2024.
Complaint Details
The complaint investigation found no deficiencies and no substantiated issues.
Findings
No deficiencies were identified at the time of the survey or as a result of the complaint visit.
Report Facts
Survey duration days: 4
Facility census: 92
Inspection Report
Follow-Up
Census: 92
Deficiencies: 0
Date: 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
Immediate Jeopardy
Census: 132
Deficiencies: 22
Date: Aug 10, 2023
Visit Reason
The visit was conducted due to multiple complaints and concerns regarding resident care, safety, medication administration, staffing, and regulatory compliance at Wilmington Nursing & Rehabilitation Center.
Findings
The facility was found to have multiple deficiencies including failure to provide immediate access to emergency personnel, inadequate environment and grievance handling, failure to protect residents from abuse and involuntary seclusion, incomplete PASARR screenings, deficient care planning, inadequate assistance with activities of daily living, failure to provide appropriate treatments and medications, insufficient nursing staff leading to delayed medication administration, poor pressure ulcer care, inadequate pain management, failure to monitor hydration and nutrition, and poor ventilation in the dementia unit. Immediate jeopardy was identified due to insufficient nursing staff resulting in delayed critical medication administration.
Deficiencies (22)
F0562 - The facility failed to provide immediate access to resident R131 during an emergency on 3/8/23, delaying EMS entry and care.
F0584 - The facility failed to maintain a safe, clean, and homelike environment in multiple units with dirty floors, peeling wallpaper, and inadequate ventilation.
F0585 - The facility failed to ensure residents and representatives were informed about grievance procedures and failed to respond to grievances promptly.
F0600 - The facility failed to protect residents from physical abuse by resident R26 who physically abused seven residents multiple times over 15 months.
F0603 - The facility failed to prevent involuntary seclusion of residents R41 and R45 by securing their room doors without physician authorization.
F0610 - The facility failed to thoroughly investigate an abuse allegation involving resident R179, lacking interviews with direct care staff.
F0644 - The facility failed to complete PASARR screenings following new psychotic disorder diagnoses for residents R3 and R179.
F0656 - The facility failed to develop and implement comprehensive person-centered care plans for residents R87, R129, R281, and R101 addressing hearing, pain, and pressure reducing devices.
F0657 - The facility failed to conduct interdisciplinary care plan conferences with required team members and failed to ensure resident/responsible party participation for residents R65, R71, and R141.
F0677 - The facility failed to provide adequate assistance with activities of daily living for residents R79 and R479, including grooming and fall prevention measures.
F0684 - The facility failed to provide treatments, medications, monitoring, and assessments as ordered for multiple residents, including failure to administer medications timely due to insufficient nursing staff on 7/21/23.
F0685 - The facility failed to accurately document fall risk assessments for residents R1, R30, and R36, resulting in inaccurate risk scores.
F0686 - The facility failed to provide appropriate pressure ulcer care and prevention for residents R140, R38, and R36, resulting in avoidable pressure ulcers and harm.
F0688 - The facility failed to provide appropriate care to maintain or improve range of motion and failed to provide necessary orthotic devices for residents R16 and R36.
F0689 - The facility failed to provide adequate supervision to prevent accidents for residents R26 and R91, resulting in falls with injuries and hospitalizations.
F0690 - The facility failed to assess and develop individualized toileting plans and failed to ensure resident R86 was offered and assisted with toileting, resulting in urinary tract infection and hospitalization.
F0692 - The facility failed to ensure residents R86, R135, and R137 received adequate hydration and monitoring, resulting in hospitalizations for dehydration and hypernatremia.
F0697 - The facility failed to monitor and treat pain adequately for residents R38, R113, and R134, including failure to document pain assessments and provide pain medication as ordered.
F0758 - The facility failed to ensure sufficient nursing staff to administer critical medications timely on 7/21/23, resulting in delayed insulin administration for multiple residents and an Immediate Jeopardy.
F0806 - The facility failed to ensure residents received food preferences as evidenced by resident R100 not receiving eggs for breakfast as requested.
F0842 - The facility failed to accurately document post-fall assessments for residents R1, R30, and R36, resulting in inaccurate fall risk scores.
F0923 - The facility failed to ensure adequate outside ventilation in the Arcadia unit due to an out-of-service AC unit.
Report Facts
Residents not administered medications or treatments: 15
Residents not administered medications or treatments: 35
Resident census: 132
Fluid intake (ml): 240
Fluid intake (ml): 1936
Fluid intake (ml): 23
Fall risk score: 17
Fall risk score: 3
Fall risk score: 16
Fall risk score: 6
Pain score: 8
Pain score: 6
Pain score: 0
Pressure ulcer size (cm): 3
Pressure ulcer size (cm): 3
Medication administration delay (hours): 3.5
Medication administration delay (hours): 2.5
Medication administration delay (hours): 4
Medication administration delay (hours): 4
Medication administration delay (hours): 2.5
Medication administration delay (hours): 4
Medication administration delay (hours): 3.5
Medication administration delay (hours): 2.5
Medication administration delay (hours): 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | NHA | Named in multiple interviews and exit conferences regarding findings |
| E2 | DON | Named in multiple interviews and exit conferences regarding findings |
| E4 | RCD | Named in multiple interviews and exit conferences regarding findings |
| E18 | VPO | Named in multiple interviews and exit conferences regarding findings |
| E36 | Agency LPN | Observed waiting to start medication pass on 7/21/23 |
| E22 | LPN/UM | Interviewed about medication pass delays and staffing on 7/21/23 |
| E43 | RN | Assigned to Dover Unit med cart on 7/21/23 |
| E37 | LPN/Wound Care | Reassigned to Heritage Unit med cart on 7/21/23 |
| E40 | RN/Staff Development | Assigned to Dover Unit med cart on 7/21/23 |
| E41 | LPN | Interviewed about medication pass on 7/21/23 |
| E30 | Agency LPN | Administered meds in Arcadia Unit on 7/21/23 |
| E56 | Dietician | Interviewed about hydration and nutrition monitoring |
| E14 | Therapy Director | Interviewed about contracture measurements and therapy |
| E26 | Rehab Director | Interviewed about care plan and therapy for R71 |
| E28 | LPN | Observed repositioning resident with pain |
| E62 | CNA | Interviewed about toileting assistance for R86 |
| E61 | CNA | Interviewed about documentation of care tasks |
| E4 | Corporate Consultant | Interviewed about medication regimen reviews |
| E15 | LPN | Confirmed fall risk assessment scores for R30 |
| E24 | ADON | Interviewed about bladder and bowel assessments |
| E21 | RN MDS Coordinator | Interviewed about assessments and hydration monitoring |
| E31 | LPN | Interviewed about vital signs and medication administration |
| E50 | LPN | Interviewed about nail care and privacy curtain for R79 |
| E29 | CNA | Interviewed about nail care for R79 |
| E8 | TNA | Interviewed about supervision of aggressive resident R26 |
| E5 | CNA | Interviewed about supervision of aggressive resident R26 |
| E6 | CNA | Interviewed about supervision of aggressive resident R26 |
| E38 | Director of Housekeeping & Laundry | Confirmed environmental deficiencies |
| E39 | Director of Maintenance | Confirmed poor ventilation in Arcadia unit |
Inspection Report
Immediate Jeopardy
Deficiencies: 29
Date: Aug 10, 2023
Visit Reason
The visit was conducted due to a facility inspection involving multiple areas of compliance including resident rights, care, medication administration, staffing, infection control, and safety.
Findings
The facility was found deficient in multiple areas including failure to provide adequate resident care, medication errors, insufficient staffing leading to delayed medication administration, inadequate infection control practices, failure to maintain safe environment and equipment, and lack of required staff training. Immediate Jeopardy was identified related to medication administration delays and staffing shortages.
Deficiencies (29)
F0550: The facility failed to ensure residents were treated with respect and dignity, including staff eating in front of residents and entering rooms without knocking.
F0578: The facility failed to offer two residents the opportunity to formulate an advance directive.
F0580: The facility failed to timely notify the physician of a resident's change in condition related to a shoulder dislocation.
F0584: The facility failed to provide a safe, clean, and homelike environment, including dirty floors, peeling wallpaper, inadequate ventilation, and unclean privacy curtains.
F0585: The facility failed to ensure residents and representatives were informed about grievance procedures and failed to respond to a grievance.
F0635: The facility failed to ensure accurate transcription and timely administration of anti-seizure medications for a resident, resulting in an Immediate Jeopardy.
F0644: The facility failed to complete PASARR screening following new diagnoses of psychotic disorders for two residents.
F0656: The facility failed to develop and implement comprehensive person-centered care plans for multiple residents, including addressing hearing impairment and pressure reducing devices.
F0657: The facility failed to review and revise care plans timely and ensure interdisciplinary team participation in care plan conferences.
F0677: The facility failed to provide adequate assistance with activities of daily living, including nail care and use of non-skid socks, for residents at risk of falls.
F0684: The facility failed to provide treatment and care according to orders, including failure to monitor vital signs, administer medications, provide treatments, and schedule follow-up appointments.
F0685: The facility failed to ensure timely medication administration, treatments, and monitoring for residents during night shifts due to insufficient nursing staff.
F0690: The facility failed to assess and develop individualized toileting plans and failed to provide adequate hydration to residents, resulting in hospitalization.
F0692: The facility failed to ensure residents were offered, assisted, and monitored for sufficient fluid intake to maintain hydration, resulting in hospitalizations for dehydration and hypernatremia.
F0693: The facility failed to label tube feeding formula and water flush with resident name, date, time, and rate of infusion as required.
F0695: The facility failed to provide tracheal suctioning consistent with professional standards, including failure to disinfect equipment and provide trash receptacles in resident bathrooms.
F0697: The facility failed to monitor and provide appropriate pain assessment and treatment for residents, including failure to document numerical pain scores and respond to pain behaviors.
F0725: The facility failed to ensure sufficient nursing staff to meet resident needs, resulting in delayed insulin administration and medication errors. Immediate Jeopardy was identified and abated.
F0756: The facility failed to act on irregularities identified during Medication Regimen Reviews and failed to complete monthly reviews for some residents.
F0760: The facility failed to monitor side effects of psychoactive medications and failed to perform required assessments such as AIMS testing.
F0803: The facility failed to follow menu items listed on the menu and failed to provide dietary tickets for resident meal trays.
F0812: The facility failed to procure and maintain kitchen equipment in safe working order, including non-functional ovens and dishwasher food grinders.
F0823: The facility failed to ensure adequate outside ventilation in the Arcadia unit due to a non-functioning AC unit.
F0940: The facility failed to provide required training for new and existing staff members.
F0942: The facility failed to provide required training on resident rights and facility responsibilities for one staff member.
F0943: The facility failed to provide required training on abuse, neglect, exploitation and misappropriation of resident property for three staff members.
F0944: The facility failed to provide required training for Quality Assurance and Performance Improvement (QAPI) for one staff member.
F0946: The facility failed to provide required training for Compliance and Ethics for one staff member.
F0947: The facility failed to provide required training for Behavioral Health for one staff member.
Report Facts
Deficiencies cited: 31
Resident fluid intake: 23
Medication doses missed: 24
Medication doses incorrect: 5
Residents affected: 15
Residents affected: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E53 | Housekeeping | Failed to complete required trainings including Resident Rights, Compliance and Ethics, Behavioral Health, and QAPI |
| E36 | Agency LPN | Delayed medication administration due to lack of PCC login; signed off late on insulin administration |
| E22 | LPN/Unit Manager | Arrived late for shift, delayed medication administration, did not sign narcotic count, confirmed staffing shortages |
| E43 | RN | Failed to disinfect glucometer between uses; delayed medication administration |
| E40 | RN/Staff Development | Reassigned to med cart due to staffing shortage; delayed medication administration |
| E4 | Regional Clinical Director | Confirmed medication administration record lacked numerical pain assessments and incomplete medication regimen review responses |
| E16 | HR Director | Confirmed lack of required staff trainings for E53 |
| E24 | Former ADON/Infection Preventionist | Resigned; facility lacked trained infection preventionist after departure |
Inspection Report
Annual Inspection
Census: 136
Deficiencies: 10
Date: 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)
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
Date: 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)
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
Date: Jun 28, 2022
Visit Reason
An unannounced complaint survey was conducted regarding food services, kitchen sanitation, and pest management.
Complaint Details
The complaint was about food services, kitchen sanitation, and pest management. The survey found no deficiencies.
Findings
No deficiencies were identified during the survey.
Report Facts
Facility census: 126
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Nov 25, 2019
Visit Reason
The inspection was conducted to investigate complaints regarding failure to provide adequate care including nail grooming, feeding tube care, food temperature, accurate documentation of transfers, and infection prevention and control practices.
Complaint Details
The visit was complaint-related, investigating multiple concerns including inadequate nail care, improper feeding tube care, food temperature issues, inaccurate transfer documentation, and infection control failures. The complaints were substantiated based on observations, interviews, and record reviews.
Findings
The facility was found deficient in multiple areas including failure to provide nail care for a resident unable to perform ADLs, improper verification of feeding tube placement, serving food at unappetizing temperatures, inaccurate documentation of resident transfers, and inadequate infection prevention and control practices including improper PPE use and failure to label contaminated linen.
Deficiencies (5)
F 0677: The facility failed to provide nail care for one resident unable to perform activities of daily living, resulting in long and broken fingernails.
F 0693: The facility failed to ensure proper feeding tube placement verification by staff, who used auscultation instead of aspirating gastric contents before medication administration.
F 0804: The facility failed to serve food and drink at appetizing temperatures, with meal items such as chicken and pasta served below acceptable temperatures.
F 0842: The facility failed to ensure accurate documentation of resident transfers, with staff documenting fewer staff assisting than actually required and observed.
F 0880: The facility failed to implement an effective infection prevention and control program, including failure to label contaminated linen, improper PPE use by staff and visitors, and inadequate hand hygiene.
Report Facts
Residents sampled for nail care: 44
Feeding tube residents sampled: 2
Meal test trays observed: 2
Transfers documented in September 2019: 26
Transfers documented in October 2019: 29
Transfers documented November 1-19, 2019: 23
Staff statements: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Director of Nursing (DON) | Named in multiple findings including nail care, feeding tube verification, and infection control. |
| E9 | Certified Nursing Assistant (CNA) | Interviewed regarding nail care for resident R4. |
| E11 | Licensed Practical Nurse (LPN) | Observed administering medication via feeding tube improperly and hand hygiene failures. |
| E12 | Licensed Practical Nurse (LPN), Nurse Supervisor | Interviewed about feeding tube placement verification and hand hygiene observation. |
| E4 | Food Service Director (FSD) | Observed serving food at unappetizing temperatures and PPE failure. |
| E5 | Assistant Director of Nursing (ADON) | Involved in review of feeding tube findings and transfer documentation investigation. |
| E3 | Assistant Director of Nursing (ADON) | Involved in transfer documentation investigation. |
| E6 | Certified Nursing Assistant (CNA) | Interviewed about transfer assistance for resident R83. |
| E7 | Housekeeping Director | Interviewed about laundry procedures and labeling of contaminated linen. |
| E8 | Certified Nursing Assistant (CNA) | Interviewed about laundry procedures and labeling of contaminated linen. |
| E10 | Certified Nursing Assistant (CNA) | Interviewed about laundry procedures and labeling of contaminated linen. |
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