Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Regency Healthcare & Rehab Center during CMS and state inspections, most recent first.
Two residents experienced deficiencies in care: one had a soiled and wet wound dressing left unchanged despite a physician's order and visible need, while another's ER discharge orders for PEG site cellulitis were not properly reviewed with the on-call provider or accurately transcribed by an LPN, resulting in staff being unaware of the new treatment order.
A resident with dementia did not receive timely follow-up dental services after refusing an initial exam and treatment, despite a provider's recommendation and a physician's order for dental evaluation. Nursing staff did not schedule the necessary follow-up, and the resident's family was not notified of any dental consults, resulting in a significant delay in dental care.
The facility failed to implement person-centered care plans for three residents, including a Spanish-speaking resident without a communication plan, a resident with an inadequate activity plan, and a resident with multiple falls due to unmet toileting needs. These deficiencies highlight the facility's inability to meet individual resident needs effectively.
A resident with dementia and bipolar disorder did not receive quetiapine fumarate as ordered due to the medication being unavailable and delayed delivery from the pharmacy. The facility failed to notify the physician promptly about the unavailability, resulting in missed doses. The issue was confirmed through staff interviews and discussed with facility leadership.
The facility did not ensure a certified food protection manager was present during all hours of operation in the food and nutrition service. Only one staff member with the necessary certification was scheduled to work part-time, while two other certified staff members were not scheduled at all. This absence of coverage increases the risk of foodborne outbreaks for vulnerable populations.
Two residents with cognitive impairments engaged in repeated aggressive interactions, including throwing water and hitting with a toilet seat cover, due to the facility's failure to effectively implement its abuse prevention program.
The facility failed to ensure accurate MDS assessments for three residents, resulting in discrepancies in their documented status. A resident's preferred language was incorrectly recorded, another resident's medication usage was not accurately reflected, and a third resident's physical limitations were inaccurately documented. These issues were confirmed during interviews and discussed with facility leadership.
A facility failed to coordinate with the PASRR program for a resident admitted without a known mental health diagnosis. After admission, the resident was found to have a history of depression, anxiety, and paranoia, and was prescribed medications for these conditions. Despite worsening anxiety and recommendations for further psychiatric evaluation, the facility did not submit a referral to the PASRR office, indicating a lapse in care coordination.
A resident with dementia experienced a decline in urinary continence and multiple falls related to toileting needs. Despite being a high fall risk, the facility did not implement a toileting program, leading to continued falls and incontinence issues. Observations and staff interviews confirmed the resident's need for supervision, which was not adequately provided.
A resident who spoke only Spanish and required an interpreter was not provided with translation services during two post-fall assessments. Documentation showed the resident was unable to communicate what happened due to language barriers, and there was no evidence that translation services were used during these incidents, despite facility policy requiring meaningful access for individuals with limited English proficiency.
A resident who was completely dependent on staff and required two-person assistance for all activities, including showering, was left in the care of a single aide during a shower. This led to the dislodgement of the resident's nephrostomy tube and multiple abrasions and bruises, requiring two emergency room visits for evaluation and treatment. Staff interviews and documentation confirmed that the care plan for two-person assistance was not followed, resulting in harm.
A resident admitted with seizure and anxiety diagnoses did not receive multiple doses of three ordered medications because staff failed to complete and send required C2 prescription forms to the pharmacy. As a result, the pharmacy did not deliver the medications, and staff documented missed doses over several days while attempting to resolve the issue.
A resident admitted with seizure and anxiety diagnoses did not receive prescribed controlled medications because the required C2 forms were not completed by the admitting MD or on-call NP. Despite repeated notifications from nursing staff, the necessary documentation was not provided to the pharmacy, resulting in the resident missing multiple doses of seizure and anxiety medications over a period of more than sixty hours.
A resident with normal cognitive function alleged inappropriate sexual contact by a CNA during care. Although the allegation was disclosed to multiple staff members and led to informal assignment changes, the incident was not reported to the Administrator or State Agency within the required timeframe. The delay in reporting occurred because staff assumed others had already reported the incident, resulting in a three-day lapse before authorities were notified.
A resident with a care plan for aggression was verbally abused by a staff member in the dining room after feeling ignored. The resident expressed frustration, leading to a verbal altercation with the staff member, who used derogatory language. Witnesses confirmed the exchange, highlighting the facility's failure to protect the resident from verbal abuse.
A facility failed to ensure an accurate MDS assessment for a resident's hearing status. The resident was admitted with a hearing aid, but the MDS incorrectly noted no hearing appliance use. This error was confirmed by the RNAC and discussed with the NHA and DON.
Failure to Follow Physician Orders and Properly Transcribe Readmission Orders
Penalty
Summary
For one resident, a failure to follow the physician's order for wound care was observed. The resident, who had intact cognition and required assistance with personal care, had a physician's order to have a right wrist skin tear cleansed and dressed daily and as needed. Despite the dressing being visibly soiled and wet after a shower, the nurse on duty did not change it, stating that the dressing was scheduled to be changed later in the day. The resident expressed an expectation that the dressing would be changed immediately due to its condition, but the nurse walked away without addressing the issue. The Director of Nursing confirmed that the dressing should have been changed when it was found to be soiled or wet, not just according to the scheduled time. For another resident, the facility failed to ensure that re-admission orders from the emergency room were properly reviewed and transcribed. Upon return from the ER with a diagnosis of cellulitis at the PEG tube site, the resident was to receive Bacitracin ointment twice daily for ten days. The LPN entered the order into the electronic medical record without reviewing the ER discharge order with the facility's on-call provider, as required by facility protocol. Additionally, the night shift nursing staff was unaware of the new order, and the RN/House Supervisor confirmed that the standard process of reviewing discharge orders with the provider was not followed.
Failure to Provide Timely Follow-Up Dental Services
Penalty
Summary
A resident with dementia was admitted to the facility and later refused a dental exam and treatment, with the dental provider recommending pre-sedation for any further dental care. The dental consultation report included a handwritten note instructing nursing staff to check the oral cavity for follow-up needs and to make a follow-up dental appointment. Despite a physician's order for a dental consult and documentation of the resident's moderate cognitive impairment, there was no evidence that a follow-up dental appointment was scheduled or completed until much later. The resident's family member reported not being notified of any dental consults and observed that the resident's teeth had not been cleaned by a dentist for about a year. Facility leadership confirmed that the follow-up dental appointment had not occurred until the day of the surveyor's inquiry.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for three residents, leading to deficiencies in meeting their individual needs. For one resident, who was admitted with a preferred language of Spanish, the facility did not create a communication care plan addressing the language barrier until two months after admission. This oversight occurred despite the resident's admission evaluation indicating a need for translation services. The resident was discharged before the care plan was implemented. Another resident's care plan for activities lacked measurable objectives and timeframes, failing to address the resident's medical, mental, and psychosocial needs. Additionally, a third resident, who had multiple falls related to toileting needs, did not have a person-centered care plan to address incontinence and prevent further falls. The facility did not develop an appropriate care plan until after the survey findings were reviewed with the nursing home administrator.
Failure to Administer Quetiapine Fumarate as Ordered
Penalty
Summary
The facility failed to ensure the administration of quetiapine fumarate (Seroquel) as ordered by the physician for a resident diagnosed with dementia and bipolar disorder. The resident was admitted with a care plan that included the use of antipsychotic medication to manage aggressive behaviors. On November 7, 2024, a physician's order was documented for quetiapine fumarate 50 mg to be administered twice daily. However, on December 3, 2024, a nurse noted that the medication was not available and reordered it from the pharmacy. Despite this, the medication was not delivered, resulting in missed doses on December 3 and December 4, 2024. The issue was compounded by the failure to notify the physician immediately when the medication was unavailable. Interviews with facility staff confirmed that the resident missed three doses of the medication due to the pharmacy's delay in delivery. The facility's Nursing Home Administrator (NHA) acknowledged that the physician was not informed promptly about the medication's unavailability. These findings were discussed with the facility's administrative and clinical leadership during the exit conference.
Lack of Certified Food Protection Manager Coverage
Penalty
Summary
The facility failed to ensure that a qualified person in charge was present during all hours of operation in the food and nutrition service. This deficiency was identified through observation and interview, revealing that only one staff member, the Food Service Manager, possessed a valid Food Protection Manager certificate from an Accredited Food Safety Program. This individual was scheduled to work only seventeen days out of twenty-eight in December 2024 and eight days out of fourteen in January 2025. The other two staff members with the necessary certification were not scheduled to work at all during this period. The absence of a certified food protection manager during all hours of operation increases the risk of a foodborne outbreak, particularly for vulnerable populations in the facility.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents, R42 and R43, from physical abuse by each other. R43, who was admitted with diagnoses including dementia and bipolar disorder, exhibited aggressive behaviors such as throwing water and hitting another resident with a toilet seat cover. Despite being care planned for these behaviors, R43 continued to engage in aggressive acts against R42 on multiple occasions, including throwing water on R42 and hitting R42 with a toilet cover. R42, admitted with diagnoses including depression, anxiety disorder, and dementia, was also involved in aggressive incidents. R42's care plan included interventions for impaired cognition and physical aggression. On one occasion, R42 hit R43 over the head with a toilet seat cover without provocation. The facility's failure to effectively manage and prevent these aggressive interactions between R42 and R43 resulted in repeated incidents of physical abuse. The facility's abuse prevention program, which was supposed to protect residents from abuse by anyone, including other residents, was not effectively implemented. The repeated incidents of aggression between R42 and R43 indicate a failure to ensure the safety and well-being of these residents, as evidenced by the multiple documented incidents of physical abuse.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate MDS assessments for three residents, leading to discrepancies in their documented status. One resident, admitted with Spanish as their preferred language, was incorrectly documented as preferring English in their admission MDS assessment. Another resident, who had an active physician's order for the anticonvulsant medication Depakote, was not accurately reflected as taking the medication in their quarterly MDS assessment. A third resident, admitted with a stroke diagnosis and impaired range of motion in both lower extremities, was inaccurately documented as having no functional limitations in their admission MDS assessment. These inaccuracies were confirmed during interviews with the RNAC and discussed during the exit conference with facility leadership.
Failure to Coordinate with PASRR Program for Resident with Mental Health History
Penalty
Summary
The facility failed to coordinate with the Pre-Admission Screening and Resident Review (PASRR) program for a resident who was admitted without a known or suspected mental health diagnosis. Initially, a PASRR Level 1 Screen completed by the hospital indicated no mental health issues for the resident. However, after admission, a psychiatric evaluation revealed a history of depression, anxiety, and paranoia, with previous treatment using Olanzapine, an antipsychotic medication. Despite these findings, the facility did not submit a referral to the PASRR office for a Level 1 screen. The resident was prescribed mirtazapine for depression and Xanax for anxiety shortly after admission. The care plan was updated to address these conditions, but the facility staff requested a psychiatric consultation due to worsening anxiety. The psychiatric note recommended continuing the current medications and suggested contacting the outpatient psychiatric provider for additional history, with a consideration to resume antipsychotic treatment. Despite these developments, the facility's Social Services Director confirmed that no referral to the PASRR office was made, indicating a lapse in the coordination of care for the resident.
Failure to Address Resident's Decline in Continence and Associated Falls
Penalty
Summary
The facility failed to evaluate and address a resident's decline in urinary continence, which was associated with multiple falls related to the resident's need for toileting assistance. The resident, who was admitted with dementia and had severely impaired cognition, was initially continent of urine and bowel. However, over time, the resident began exhibiting behaviors such as urinating on the floor and defecating on the air conditioning unit, indicating a decline in continence. Despite these changes, the facility did not initiate a toileting program or trial to address the resident's incontinence. The resident experienced several falls while attempting to use the bathroom independently, despite being care planned for falls related to poor safety awareness. The facility's records show that the resident was frequently incontinent of urine and bowel, yet no toileting program was implemented. The resident's care plan was updated to include offering a commode and providing incontinent care after each episode, but these measures were insufficient to prevent further falls. Observations revealed that the resident continued to attempt to use the bathroom without assistance, despite being a high fall risk and having impulsive and aggressive behaviors. Staff interviews confirmed that the resident required supervision when using the toilet, but the facility did not adequately address the resident's toileting needs. The facility's failure to evaluate the resident's toileting decline and implement a personalized toileting program contributed to the resident's continued falls and incontinence issues.
Failure to Provide Translation Services During Nursing Care
Penalty
Summary
A deficiency was identified when the facility failed to provide Spanish-speaking translation or interpretation services during nursing care for a resident with limited English proficiency. The facility's policy required meaningful access to information and services for individuals with limited English proficiency, including competent oral translation of vital information. Upon admission, the resident indicated Spanish as their preferred language and requested an interpreter for communication with healthcare staff. However, during two separate post-fall assessments, documentation showed that the resident was unable to explain what happened due to language barriers, and there was no evidence that translation services were utilized during these critical assessments. Record review and interviews confirmed that while the facility maintained a list of translation service transactions, there was no documentation of translation services being provided on the dates of the incidents in question. The absence of translation services during these events was further corroborated by the lack of relevant entries in the resident's clinical record and the facility's own transaction logs. The deficiency was discussed with facility leadership during the exit conference.
Failure to Provide Required Two-Person Assistance During Shower Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan requiring two-person assistance during showering. The resident, who had a history of traumatic brain injury, tracheostomy, enteral tube feeding, and required a nephrostomy tube for bladder drainage, was completely dependent on staff for all activities of daily living, including repositioning and showering. Despite clear documentation in the care plan and clinical records specifying the need for two-person assistance, only one staff member provided care during the shower. During the shower, the resident's nephrostomy tube became dislodged while being repositioned, and the resident sustained multiple abrasions and bruises to the face, torso, and lower extremities. The incident resulted in the resident being sent to the emergency room twice for evaluation and treatment, including replacement of the nephrostomy tube. Interviews with staff confirmed that only one aide was present in the shower room, and other aides did not assist, despite the resident's total dependence and documented need for two-person assistance. Further documentation and interviews revealed that the resident's family expressed concerns about the number of staff present during the shower and the condition of the shower bed. The facility's investigation found that the aide attempted to turn the resident alone, with the shower bed rails down, leading to the resident nearly sliding off and sustaining injuries. The failure to implement the resident's care plan for two-person assistance directly resulted in harm to the resident.
Failure to Obtain and Administer Ordered Medications Due to Incomplete C2 Forms
Penalty
Summary
A deficiency occurred when a resident was admitted with diagnoses including seizures and anxiety disorder, and physician orders were written for three medications: lacosamide, perampanel (Fycomba), and clonazepam. Despite these orders, the facility failed to obtain and administer these medications for several days following admission. Review of the Medication Administration Record (MAR) showed that multiple doses of each medication were missed over a three-day period, with staff documenting codes indicating either 'other/see nurse notes' or 'out of the facility' instead of actual administration. The clinical record and staff interviews confirmed that the required C2 prescription forms for these controlled medications were not completed and sent to the pharmacy at the time of admission, resulting in the pharmacy not delivering the medications. Further documentation revealed that staff were aware of the missing medications and communicated with the pharmacy and providers, but the necessary C2 forms were not completed and sent until several days after admission. The pharmacy confirmed receipt of the forms only after the missed doses had already occurred. The facility lacked evidence that the required forms were completed upon admission, directly leading to the resident missing multiple doses of essential seizure and anxiety medications.
Failure to Complete Required Controlled Substance Prescription Forms on Admission
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician or provider completed the required C2 forms for controlled prescription medications upon the admission of a resident with diagnoses including seizures and anxiety. The admitting physician, who also served as the Medical Director, entered orders for three controlled medications—clonazepam, lacosamide, and perampanel—into the electronic medical record, but did not complete the necessary C2 forms required by the pharmacy to dispense these medications. Nursing staff documented that only the C2 form for oxycodone was sent to the pharmacy, and the pharmacy reported not receiving prescriptions for the resident's seizure control medications. Despite being contacted multiple times by nursing staff, the nurse practitioner on call was unable to complete and return the required forms, stating that the forms would be filled out the following morning. As a result, the resident went over sixty hours without access to prescribed controlled medications, missing multiple doses of clonazepam, lacosamide, and perampanel. There was no documented explanation for the provider's inability to complete the forms, and the facility did not have a physician or provider available on weekends with the capability to fulfill this requirement. The deficiency was identified during record review and discussed with facility leadership during the exit conference.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident within the required two-hour timeframe as outlined in its own policy and state law. The resident, who had a history of stroke with left-sided weakness and demonstrated normal cognitive function, reported that a certified nursing assistant (CNA) had inappropriately touched him during care. The resident stated he had informed the former Social Work Director about the incident shortly after it occurred, and the CNA reported that he had told a nurse about the allegation. Despite these disclosures, the information was not escalated to the Administrator or the State Agency until three days after a nursing supervisor became aware of the allegation. Interviews and record reviews revealed that staff were aware of the allegation and had been informally adjusting assignments to prevent the CNA from caring for the resident, but no formal report was made. The nursing supervisor who learned of the allegation assumed that management was already aware and did not report it. The Director of Nursing and the Administrator confirmed they were unaware of the situation until notified by a state investigator, at which point the allegation was reported to the State Agency. The facility's failure to follow its policy and promptly report the abuse allegation resulted in a delay in notifying the appropriate authorities.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R95, from verbal abuse by a staff member, E6. R95, who had a care plan for physical and verbal aggression, was involved in an incident in the dining room where he felt ignored by E6 and expressed his frustration by yelling. In response, E6 engaged in a verbal altercation with R95, using curse words and derogatory language. This incident was witnessed by other staff members, who provided written statements confirming the exchange of insults between R95 and E6. The incident report and witness statements indicate that R95 was frustrated due to a missing meal ticket and felt ignored by E6, leading to the verbal confrontation. Despite R95's care plan interventions, which included listening to the resident and trying to calm him, E6's response escalated the situation. The facility's failure to manage the situation appropriately and protect R95 from verbal abuse resulted in a deficiency finding during the survey.
Inaccurate MDS Assessment for Resident's Hearing Status
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident regarding their hearing status. The resident was admitted to the facility with a hearing aid and charger, as documented in their inventory list. However, during an annual MDS assessment, it was incorrectly recorded that the resident did not use a hearing aid or other hearing appliance. This discrepancy was identified during a review of the resident's care plan, which noted that the resident was at risk for impaired communication and was very hard of hearing. The error in the MDS was confirmed during an interview with the Registered Nurse Assessment Coordinator (RNAC). The findings were discussed with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) during the exit conference.
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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) |
|---|---|---|---|---|
| Gilpin Hall | 0.5 mi | ★★★★★ | 11 | 0 |
| Complete Care At Hillside Llc | 0.8 mi | ★★★★★ | 4 | 0 |
| Kentmere Rehabilitation And Healthcare Center | 0.9 mi | ★★★★★ | 5 | 0 |
| Excelcare At Wilmington Llc | 0.9 mi | ★★★★★ | 2 | 0 |
| Wilmington Nursing & Rehabilitation Center | 3 mi | — | 26 | 2 |
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