Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Excelcare At Wilmington Llc during CMS and state inspections, most recent first.
A resident with a history of bipolar disorder was later diagnosed with delusional disorder and began exhibiting escalating delusional behaviors, leading to the initiation of a new atypical anti-psychotic medication. The facility did not request a new PASARR evaluation following these significant changes in the resident's psychiatric condition and medication regimen.
The facility failed to ensure accurate medical record documentation for two residents. One resident's episodes of agitation and aggression were not properly recorded in behavior monitoring logs, despite evidence of such behaviors. Another resident, who was under an NPO order due to stroke and aphasia, had multiple instances of oral intake incorrectly documented, and progress notes contained conflicting information about communication abilities and lab results. These inaccuracies were confirmed by staff interviews.
The facility failed to ensure isolation carts were fully stocked, an LPN did not intervene when a resident consumed a dropped pill, and a CNA did not perform proper hand hygiene after wiping a resident's nose. These actions were contrary to the facility's infection prevention and control policies.
A resident with intact cognition and dependent on staff assistance was instructed to use his brief instead of being assisted to the bathroom, despite being on a toileting program. Staff confirmed the resident was on a check and change routine, and both the DON and Administrator acknowledged this was a dignity issue.
The facility failed to implement a toileting program for a cognitively intact resident, despite his ability to communicate his needs. Instead, the resident was subjected to a check and change routine, contrary to the facility's policy on promoting continence and quality of life. Interviews revealed inconsistencies in staff awareness and implementation of the toileting program.
Failure to Initiate PASARR Review After Significant Change in Condition
Penalty
Summary
The facility failed to initiate a new PASARR (Pre-admission Screening and Resident Review) evaluation for a resident with mental health diagnoses when there was a significant change in condition. The resident, who had a history of bipolar disorder and was previously determined to require a PASARR Level II without specialized services, was later diagnosed with delusional disorder, a diagnosis not present in the initial PASARR evaluation. Following this change, the resident exhibited escalating delusional behaviors and was started on a new atypical anti-psychotic medication (Rexulti) for delusional disorder. Despite these significant changes in the resident's psychiatric condition and medication regimen, the facility did not request a new PASARR evaluation as required.
Failure to Maintain Accurate Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with professional standards for two residents. For one resident with a diagnosis including bipolar disorder, documentation inconsistencies were identified on two separate days. Despite incidents involving agitation and aggressive behavior, including a heated interaction with another resident and an episode where the resident displayed physical aggression with a knife, the Behavior Monitoring Record for both dayshift periods inaccurately recorded zero instances of agitated behavior. Interviews with involved parties confirmed the presence of agitation and aggression during these incidents, which were not reflected in the official records. For another resident admitted with stroke and aphasia, the facility's records showed multiple discrepancies. Although the resident was under an NPO (nothing by mouth) order, staff documented oral fluid intake on four occasions. Additionally, progress notes contained conflicting information regarding the resident's ability to communicate, with one note stating the resident was aphasic and nonverbal, while also indicating clear speech. Another note referenced recent lab results that did not exist in the resident's chart. The DON confirmed that the documentation of oral intake was erroneous and that the resident was nonverbal during the stay.
Inadequate Stocking of Isolation Carts and Poor Infection Control Practices
Penalty
Summary
The facility failed to ensure that four out of four isolation carts were fully stocked with necessary supplies to promote infection control. During observations, it was noted that isolation carts outside specific rooms lacked essential items such as face shields, gloves, and N95 masks. Interviews with staff, including an LPN, CNA, Housekeeping Director, Infection Preventionist, and the Director of Nursing, revealed inconsistencies in the responsibility and execution of restocking these carts. The Infection Preventionist admitted to sometimes only visualizing the carts without opening them to check for supplies, and the Director of Nursing confirmed that there was no single person responsible for daily stocking of the carts. During a medication pass, an LPN failed to intervene when a resident dropped a pill on the floor and subsequently consumed it. The resident, who had diagnoses including hypertension, seizure, anemia, and overactive bladder, picked up the pill and placed it in his mouth without the LPN stopping him. The LPN later confirmed that she should have discarded the contaminated pill and provided a new one. Additionally, a CNA did not perform proper hand hygiene after wiping a resident's nose, which had a yellowish substance coming out of it. The resident had diagnoses of dementia, schizophrenia, anxiety, and major depressive disorder. The Director of Nursing stated that she would have expected the staff to wash or sanitize their hands after such an action. The facility's policies on infection prevention and control, as well as hand hygiene, were not adhered to in these instances, leading to potential risks of infection transmission.
Failure to Maintain Resident Dignity in Toileting
Penalty
Summary
The facility failed to ensure that a resident (R106) was treated with dignity in toileting. R106, who was admitted with diagnoses of toxic encephalopathy and sepsis, had intact cognition and was dependent on staff assistance for care. Despite being on a toileting program for bowel and bladder incontinence, the care plan did not include this intervention. Observations and interviews revealed that staff instructed R106 to use his brief instead of assisting him to the bathroom, which he found undignified and distressing. The CNA confirmed that R106 was not on a toileting program but was instead on a check and change routine every two to three hours. The LPN acknowledged that the CNA task page indicated a toileting program, but staff opted to change R106's brief after he used it due to the need for a mechanical lift to get him out of bed. Further interviews with the Director of Nursing (DON) and the Administrator confirmed that it was inappropriate and a dignity issue for staff to tell R106 to use his brief when he requested to be taken to the bathroom. The facility's policy on promoting and maintaining resident dignity emphasized the importance of respecting and enhancing residents' quality of life, which was not upheld in this case. The failure to follow the toileting program and the inappropriate instructions given to R106 led to a deficiency in maintaining the resident's dignity.
Failure to Implement Toileting Program for Cognitively Intact Resident
Penalty
Summary
The facility failed to ensure that a resident, who was admitted with multiple diagnoses including toxic encephalopathy, sepsis, and acute respiratory failure, was on a proper toileting program to enhance his continence. Despite the resident's intact cognition and ability to communicate his need to use the bathroom, the care plan did not include a toileting program. Instead, the resident was subjected to a check and change routine every two to three hours, which did not align with his needs or the facility's policy on promoting continence and quality of life. Observations and interviews revealed discrepancies between the care plan and the actual care provided. The resident expressed that he could tell when he needed to use the bathroom, but staff instructed him to use his brief instead. Interviews with CNAs and LPNs indicated a lack of consistent implementation of the toileting program, with some staff unaware that the resident was supposed to be on such a program. The Director of Nursing confirmed that the resident should have been offered toileting options like a urinal or bedpan, even if a mechanical lift was required for mobility. Further interviews with the Director of Rehabilitation confirmed that the resident was capable of using a urinal or bedpan with assistance. The facility's policy on bowel and bladder management emphasized the importance of assessing residents' needs and developing a care plan to promote continence. However, the failure to implement a toileting program for the resident, despite his ability to communicate his needs, highlighted a significant lapse in care and adherence to the facility's policies.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Wilmington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency Healthcare & Rehab Center | 0.9 mi | ★★★★★ | 0 | 0 |
| Kentmere Rehabilitation And Healthcare Center | 1.1 mi | ★★★★★ | 5 | 0 |
| Complete Care At Hillside Llc | 1.2 mi | ★★★★★ | 4 | 0 |
| Gilpin Hall | 1.3 mi | ★★★★★ | 11 | 0 |
| Stonegates | 2.3 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.