The Vardell Report.Wilmington Nursing & Rehabilitation Center

Across 5 inspections from August 2023 to May 2026, state surveyors documented 105 findings at Wilmington Nursing & Rehabilitation Center; 105 have a recorded correction; CMS lists 6 enforcement actions in the window.

Inspections

5

2023–2026, complaint and standard

Findings

105

Deficiencies cited by state inspectors

Corrected

105

Of 105 findings, with a recorded correction date

Penalties

6

4 fines; payment not published, 2 closed

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. May 112026

   Complaint investigation

   19 findings

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level KImmediate jeopardyCorrected Aug 26, 2026
   • F760Ensure that residents are free from significant medication errors.Level JImmediate jeopardyCorrected Jun 16, 2026
   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Aug 26, 2026
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level GActual harmCorrected Aug 26, 2026
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Jun 16, 2026
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level ENo actual harm, potential for moreCorrected Aug 26, 2026
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Aug 26, 2026
   • F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level DNo actual harm, potential for moreCorrected Jun 16, 2026
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Aug 26, 2026
   • F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected Aug 26, 2026
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Aug 26, 2026
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Aug 26, 2026
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Aug 26, 2026
   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level DNo actual harm, potential for moreCorrected Aug 26, 2026
   • F770Provide timely, quality laboratory services/tests to meet the needs of residents.Level DNo actual harm, potential for moreCorrected Jun 16, 2026
   • F777Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.Level DNo actual harm, potential for moreCorrected Sep 22, 2026
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Jun 16, 2026
   • F865Have a plan that describes the process for conducting QAPI and QAA activities.Level DNo actual harm, potential for moreCorrected Jun 16, 2026
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jun 16, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Dec 42025

   Standard health inspection

   16 findings

   The same visit included a complaint investigation.

   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level ENo actual harm, potential for moreCorrected Jan 9, 2026
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jan 9, 2026
   • F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Level DNo actual harm, potential for moreCorrected Jan 9, 2026
   • F635Provide doctor's orders for the resident's immediate care at the time the resident was admitted.Level DNo actual harm, potential for moreCorrected Jan 9, 2026
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Jan 9, 2026
   • F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreCorrected Jan 9, 2026
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Jan 9, 2026
   • F679Provide activities to meet all resident's needs.Level DNo actual harm, potential for moreCorrected Jan 9, 2026
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jan 9, 2026
   • F691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Jan 9, 2026
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Jan 9, 2026
   • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Jan 9, 2026
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Jan 9, 2026
   • F770Provide timely, quality laboratory services/tests to meet the needs of residents.Level DNo actual harm, potential for moreCorrected Jan 9, 2026
   • F791Provide or obtain dental services for each resident.Level DNo actual harm, potential for moreCorrected Jan 9, 2026
   • F574The resident has the right to receive notices in a format and a language he or she understands.Level CPotential for minimal harmCorrected Jan 9, 2026

   Enforcement Action

   Civil money penalty, $18,688 imposed May 11, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of December 4, 2025, the nearest before the penalty date.

   Enforcement Action

   Civil money penalty, $191,981 imposed May 11, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of December 4, 2025, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Oct 22024

   Standard health inspection

   25 findings

   The same visit included a complaint investigation.

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Jan 15, 2025
   • F760Ensure that residents are free from significant medication errors.Level GActual harmCorrected Nov 18, 2024
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Nov 18, 2024
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Nov 18, 2024
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level ENo actual harm, potential for moreCorrected Jan 15, 2025
   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level ENo actual harm, potential for moreCorrected Nov 18, 2024
   • F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Level ENo actual harm, potential for moreCorrected Nov 18, 2024
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jan 15, 2025
   • F887Educate 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.Level ENo actual harm, potential for moreCorrected Nov 18, 2024
   • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
   • F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level DNo actual harm, potential for moreCorrected Jan 15, 2025
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
   • F688Provide 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.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Jan 15, 2025
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
   • F693Ensure 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.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
   • F732Post nurse staffing information every day.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
   • F807Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
   • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level BPotential for minimal harmCorrected Nov 18, 2024

   Enforcement Action

   Civil money penalty, $212,076 imposed October 2, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 2, 2024, the nearest before the penalty date.

   Enforcement Action

   Denial of payment imposed October 2, 2024. Status: Closed, January 15, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 2, 2024, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. Apr 102024

   Complaint investigation

   6 findings

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level JImmediate jeopardyCorrected Jun 26, 2024
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected May 13, 2024
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jun 26, 2024
   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected May 13, 2024
   • F838Conduct 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.Level DNo actual harm, potential for moreCorrected May 13, 2024
   • F837Establish 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.Level CPotential for minimal harmCorrected May 13, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

5. Aug 102023

   Standard health inspection

   39 findings

   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level KImmediate jeopardyCorrected Sep 25, 2023
   • F760Ensure that residents are free from significant medication errors.Level KImmediate jeopardyCorrected Sep 25, 2023
   • F635Provide doctor's orders for the resident's immediate care at the time the resident was admitted.Level JImmediate jeopardyCorrected Dec 6, 2023
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level JImmediate jeopardyCorrected Dec 6, 2023
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Sep 25, 2023
   • F692Provide enough food/fluids to maintain a resident's health.Level GActual harmCorrected Sep 25, 2023
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Sep 25, 2023
   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Dec 6, 2023
   • F908Keep all essential equipment working safely.Level FNo actual harm, potential for moreCorrected Sep 25, 2023
   • F578Honor 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.Level ENo actual harm, potential for moreCorrected Dec 6, 2023
   • F584Honor 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.Level ENo actual harm, potential for moreCorrected Dec 6, 2023
   • F585Honor 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.Level ENo actual harm, potential for moreCorrected Sep 25, 2023
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level ENo actual harm, potential for moreCorrected Dec 6, 2023
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Dec 6, 2023
   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level ENo actual harm, potential for moreCorrected Sep 25, 2023
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level ENo actual harm, potential for moreCorrected Sep 25, 2023
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level ENo actual harm, potential for moreCorrected Sep 25, 2023
   • F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel ENo actual harm, potential for moreCorrected Sep 25, 2023
   • F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level ENo actual harm, potential for moreCorrected Sep 25, 2023
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Dec 6, 2023
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Sep 25, 2023
   • F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreCorrected Dec 6, 2023
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Sep 25, 2023
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Dec 6, 2023
   • F685Assist a resident in gaining access to vision and hearing services.Level DNo actual harm, potential for moreCorrected Sep 25, 2023
   • F688Provide 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.Level DNo actual harm, potential for moreCorrected Dec 6, 2023
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Dec 6, 2023
   • F693Ensure 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.Level DNo actual harm, potential for moreCorrected Dec 6, 2023
   • F758Implement 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.Level DNo actual harm, potential for moreCorrected Dec 6, 2023
   • F803Ensure 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.Level DNo actual harm, potential for moreCorrected Dec 6, 2023
   • F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Level DNo actual harm, potential for moreCorrected Jan 31, 2024
   • F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Level DNo actual harm, potential for moreCorrected Sep 25, 2023
   • F923Have enough outside ventilation via a window or mechanical ventilation, or both.Level DNo actual harm, potential for moreCorrected Sep 25, 2023
   • F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.Level DNo actual harm, potential for moreCorrected Sep 25, 2023
   • F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Level DNo actual harm, potential for moreCorrected Dec 6, 2023
   • F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Level DNo actual harm, potential for moreCorrected Dec 6, 2023
   • F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Level DNo actual harm, potential for moreCorrected Dec 6, 2023
   • F946Provide training in compliance and ethics.Level DNo actual harm, potential for moreCorrected Dec 6, 2023
   • F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Level DNo actual harm, potential for moreCorrected Sep 25, 2023

   Enforcement Action

   Civil money penalty, $20,071 imposed April 10, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of August 10, 2023, the nearest before the penalty date.

   Enforcement Action

   Denial of payment imposed April 10, 2024. Status: Closed, June 26, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of August 10, 2023, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Quality of Care, Cited in Four Inspections

   Inspectors cited F684 in August 2023, April 2024, October 2024 and May 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level K (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242526F684 across all 5 inspections, oldest to newest
2. 2

   Pressure Injury Care, Cited in Four Inspections

   Inspectors cited F686 in August 2023, April 2024, October 2024 and December 2025. This citation covers how the home prevents and treats pressure injuries (bedsores). The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242526F686 across all 5 inspections, oldest to newest
3. 3

   Infection Control, Cited in Four Inspections

   Inspectors cited F880 in August 2023, October 2024, December 2025 and May 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242526F880 across all 5 inspections, oldest to newest
4. 4

   Dignity and Resident Rights, Cited in Three Inspections

   Inspectors cited F550 in August 2023, December 2025 and May 2026. This citation covers residents’ right to dignity, to make their own choices and to communicate. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242526F550 across all 5 inspections, oldest to newest
5. 5

   Telling Families About Changes, Cited in Three Inspections

   Inspectors cited F580 in August 2023, April 2024 and May 2026. This citation covers whether the resident, their doctor and a family member are told promptly about an injury, a decline or another significant change. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242526F580 across all 5 inspections, oldest to newest
6. 6

   Care Plans, Cited in Three Inspections

   Inspectors cited F656 in August 2023, October 2024 and May 2026. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242526F656 across all 5 inspections, oldest to newest
7. 7

   Help With Daily Living, Cited in Three Inspections

   Inspectors cited F677 in August 2023, December 2025 and May 2026. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242526F677 across all 5 inspections, oldest to newest
8. 8

   Accident Hazards and Supervision, Cited in Three Inspections

   Inspectors cited F689 in August 2023, October 2024 and May 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242526F689 across all 5 inspections, oldest to newest
9. 9

   Continence and Catheter Care, Cited in Three Inspections

   Inspectors cited F690 in August 2023, April 2024 and October 2024. This citation covers continence care, catheter care and preventing urinary tract infections. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242526F690 across all 5 inspections, oldest to newest
10. 10

    Nutrition and Hydration, Cited in Three Inspections

    Inspectors cited F692 in August 2023, October 2024 and December 2025. This citation covers whether residents get enough food and fluids to stay healthy. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242526F692 across all 5 inspections, oldest to newest
11. 11

    Respiratory Care, Cited in Three Inspections

    Inspectors cited F695 in August 2023, October 2024 and May 2026. This citation covers oxygen, breathing treatments and other respiratory care. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242526F695 across all 5 inspections, oldest to newest
12. 12

    Significant Medication Errors, Cited in Three Inspections

    Inspectors cited F760 in August 2023, October 2024 and May 2026. This citation covers whether residents are free from significant medication errors. The most serious of these was recorded at level K (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242526F760 across all 5 inspections, oldest to newest
13. 13

    Citation F561, Cited in Two Inspections

    Inspectors cited F561 in October 2024 and May 2026. The agency describes it this way: Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242526F561 across all 5 inspections, oldest to newest
14. 14

    Citation F635, Cited in Two Inspections

    Inspectors cited F635 in August 2023 and December 2025. The agency describes it this way: Provide doctor's orders for the resident's immediate care at the time the resident was admitted. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242526F635 across all 5 inspections, oldest to newest
15. 15

    Accurate Assessments, Cited in Two Inspections

    Inspectors cited F641 in October 2024 and December 2025. This citation covers whether each resident’s assessment correctly records their condition. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242526F641 across all 5 inspections, oldest to newest
16. 16

    Coordinating Mental Health Screening, Cited in Two Inspections

    Inspectors cited F644 in August 2023 and December 2025. This citation covers whether assessments are coordinated with the state’s pre-admission screening for mental illness and intellectual disability (PASARR), and referrals made. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242526F644 across all 5 inspections, oldest to newest
17. 17

    Care Plan Timing and Review, Cited in Two Inspections

    Inspectors cited F657 in August 2023 and October 2024. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242526F657 across all 5 inspections, oldest to newest
18. 18

    Mobility and Range of Motion, Cited in Two Inspections

    Inspectors cited F688 in August 2023 and October 2024. This citation covers care that keeps or improves a resident’s movement and mobility. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242526F688 across all 5 inspections, oldest to newest
19. 19

    Citation F693, Cited in Two Inspections

    Inspectors cited F693 in August 2023 and October 2024. The agency describes it this way: 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. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242526F693 across all 5 inspections, oldest to newest
20. 20

    Citation F697, Cited in Two Inspections

    Inspectors cited F697 in August 2023 and October 2024. The agency describes it this way: Provide safe, appropriate pain management for a resident who requires such services. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242526F697 across all 5 inspections, oldest to newest
21. 21

    Citation F757, Cited in Two Inspections

    Inspectors cited F757 in October 2024 and December 2025. The agency describes it this way: Ensure each resident’s drug regimen must be free from unnecessary drugs. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242526F757 across all 5 inspections, oldest to newest
22. 22

    Citation F770, Cited in Two Inspections

    Inspectors cited F770 in December 2025 and May 2026. The agency describes it this way: Provide timely, quality laboratory services/tests to meet the needs of residents. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242526F770 across all 5 inspections, oldest to newest
23. 23

    Kitchen and Food Safety, Cited in Two Inspections

    Inspectors cited F812 in August 2023 and October 2024. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242526F812 across all 5 inspections, oldest to newest
24. 24

    Medical Records, Cited in Two Inspections

    Inspectors cited F842 in October 2024 and May 2026. This citation covers whether resident records are complete, accurate and kept confidential. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242526F842 across all 5 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

   Quality of Care: cited in four inspections, most seriously at level K.

2. 02

   How often are residents checked for pressure injuries and repositioned, and who is responsible for it?

   Pressure Injury Care: cited in four inspections, most seriously at level G.

3. 03

   Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

   Infection Control: cited in four inspections, most seriously at level F.

4. 04

   How do staff learn each resident’s preferences, and how is a complaint about dignity handled?

   Dignity and Resident Rights: cited in three inspections, most seriously at level E.

5. 05

   How quickly will we hear about a fall, an injury or a change in condition, and from whom?

   Telling Families About Changes: cited in three inspections, most seriously at level D.

6. 06

   How is a care plan written and reviewed here, and how do families take part in it?

   Care Plans: cited in three inspections, most seriously at level E.

7. 07

   How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?

   Help With Daily Living: cited in three inspections, most seriously at level G.

8. 08

   What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

   Accident Hazards and Supervision: cited in three inspections, most seriously at level G.

9. 09

   How is continence care scheduled, and how do you prevent urinary infections?

   Continence and Catheter Care: cited in three inspections, most seriously at level E.

10. 10

    How are weight and fluid intake tracked, and what happens when a resident starts losing weight?

    Nutrition and Hydration: cited in three inspections, most seriously at level G.

11. 11

    Who manages oxygen and breathing treatments on each shift, and how is the equipment checked?

    Respiratory Care: cited in three inspections, most seriously at level J.

12. 12

    What happened after the medication error citation, and how are high-risk drugs double-checked?

    Significant Medication Errors: cited in three inspections, most seriously at level K.

13. 13

    What changed after F561 was cited, and how do you check it now?

    Citation F561: cited in two inspections, most seriously at level D.

14. 14

    What changed after F635 was cited, and how do you check it now?

    Citation F635: cited in two inspections, most seriously at level J.

15. 15

    Who completes resident assessments, and how are they checked for accuracy?

    Accurate Assessments: cited in two inspections, most seriously at level D.

16. 16

    How do you arrange services for residents with a mental illness or an intellectual disability?

    Coordinating Mental Health Screening: cited in two inspections, most seriously at level D.

17. 17

    How often are care plans revised, and who takes part in the review?

    Care Plan Timing and Review: cited in two inspections, most seriously at level E.

18. 18

    What do you do to keep residents moving, and who provides range-of-motion care?

    Mobility and Range of Motion: cited in two inspections, most seriously at level D.

19. 19

    What changed after F693 was cited, and how do you check it now?

    Citation F693: cited in two inspections, most seriously at level D.

20. 20

    What changed after F697 was cited, and how do you check it now?

    Citation F697: cited in two inspections, most seriously at level E.

21. 21

    What changed after F757 was cited, and how do you check it now?

    Citation F757: cited in two inspections, most seriously at level D.

22. 22

    What changed after F770 was cited, and how do you check it now?

    Citation F770: cited in two inspections, most seriously at level D.

23. 23

    May we see the kitchen, and what do your own sanitation checks look like week to week?

    Kitchen and Food Safety: cited in two inspections, most seriously at level F.

24. 24

    How can a family request a resident’s records, and how are they kept accurate?

    Medical Records: cited in two inspections, most seriously at level D.

25. 25

    How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

    Insufficient nursing staff was cited in August 2023.

26. 26

    What led to the 2026 fine, and has it been paid?

    An $18,688 civil money penalty was imposed May 11, 2026. CMS publishes the fine, not whether it has been paid. The record holds six enforcement actions in the window.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Delaware state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Delaware state survey agency

  Inspection Aug 10, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Delaware state survey agency

  Inspection Apr 10, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Delaware state survey agency

  Inspection Oct 2, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Delaware state survey agency

  Inspection Dec 4, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Delaware state survey agency

  Inspection May 11, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 085028

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.