Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Davis Health And Wellness Center At Cambridge Vill during CMS and state inspections, most recent first.
The facility failed to maintain the required eight consecutive hours of RN coverage per day on multiple occasions, despite having a census of fewer than 60 residents. Review of PBJ reports, daily census postings, staffing sheets, and timecards showed that on several days no RN was scheduled or worked the required continuous hours. The Administrator, who is responsible for ensuring RN coverage, acknowledged ongoing difficulties in maintaining this requirement, citing reliance on agency RNs and the unavailability of the prior DON when agency RNs did not report for their scheduled shifts.
The facility failed to obtain and document informed consent before initiating psychotropic antidepressant medications for seven cognitively intact or mildly impaired residents with conditions such as depression, anxiety, stroke, dementia, insomnia, and falls. Physician orders and MARs showed that medications including duloxetine, sertraline, amitriptyline, trazodone, bupropion, and Prozac were administered as ordered, but EMRs lacked evidence that residents or responsible parties were informed of the medication names, purposes, risks, benefits, alternatives, or their right to refuse, and there were no signed consent forms or progress notes reflecting consent discussions. In interviews, the Case Manager and DON reported they were unaware that consent was required for psychotropic medications and acknowledged the facility had not been obtaining informed consent, while the Physician stated she was unaware consent had not been obtained and affirmed that informed consent prior to starting psychotropic medications is essential.
Surveyors found that kitchen staff failed to discard multiple expired food items stored in a reach-in refrigerator, including opened containers of sauerkraut, canned pears, canned tuna, and canned pork and beans that were kept past their labeled discard dates. A weekend cook reported that all kitchen staff were responsible for checking and discarding expired foods but acknowledged he had not checked the refrigerator and had overlooked the expired items on a prior shift. The Dietary Manager stated that perishable foods were to be discarded after 3 days and that staff should have removed the items on their discard dates, while the Administrator stated she expected kitchen staff to check for and remove expired foods daily.
A resident with chronic osteomyelitis and diabetes had an order for doxycycline 100 mg PO twice daily, but over several days eight doses were not administered because the medication was unavailable or awaiting pharmacy delivery. Multiple nurses documented the missed doses on the MAR yet did not notify the physician, with some stating they did not think or realize notification was necessary. The DON stated she expected staff to notify the provider when medications are unavailable, and the physician reported being unaware of the missed doses and stated that medications should be administered as ordered and that the provider should be notified if a medication is not available.
A resident with chronic osteomyelitis and diabetes had an order for doxycycline 100 mg PO BID, but eight consecutive doses were not administered over several days because the medication was repeatedly unavailable. Multiple nurses documented the drug as unavailable, did not consistently check the automated dispensing machine, and often failed to contact the pharmacy or request use of the backup system, while one nurse learned of a discrepancy between the pharmacy’s once-daily entry and the facility’s BID order but did not escalate it to the DON or physician. The DON stated she expected medications to be administered as ordered and that staff should use the automated dispensing machine and backup pharmacy when medications are not on hand, and the Pharmacy Manager reported that the pharmacy had entered the order incorrectly and that, if notified, the medication would have been supplied through backup processes, noting the potential risk of infection worsening from the missed doses.
A resident receiving hydroxyzine 25 mg for pruritus continued to be administered the medication three times daily because a physician-approved change to twice-daily dosing, recommended in the Consultant Pharmacist’s monthly medication regimen review, was not entered into the EMR. The DON, who received the pharmacist’s emailed report and described a process for obtaining physician signatures and updating orders, did not promptly act on the December review, resulting in ongoing administration of the higher-frequency dose until the pharmacist later alerted her that the change had not been implemented.
Three residents experienced significant medication errors due to failures in medication availability, order transcription, and timely implementation of dose changes. One resident with chronic osteomyelitis missed multiple consecutive doses of doxycycline when several nurses documented the drug as unavailable and did not promptly secure it from the pharmacy. Another resident with depression and Parkinson’s disease received 15 mg of mirtazapine nightly instead of the intended 7.5 mg after the DON mis-entered the order and the facility’s two-step verification process was not completed. A third resident with pruritus continued to receive hydroxyzine 25 mg three times daily because a physician-approved dose reduction to twice daily, identified in a pharmacist’s medication regimen review, was not promptly entered into the EMR, and the higher-frequency dosing continued until the DON eventually updated the order.
Two residents with histories of falls and related diagnoses did not have person-centered care plans addressing fall risk, despite assessments indicating the need. Both experienced multiple falls during their stays, and the required care plans were not developed or updated due to missed actions by the MDS Nurse and lack of participation in weekly IDT meetings.
The facility failed to implement a comprehensive system to monitor antibiotic use, as required by their Antibiotic Stewardship Program policy, affecting all 18 residents over a 12-month period. Monthly reports lacked necessary data such as surveillance logs and trends in infection. Staff interviews revealed a lack of oversight and responsibility, with the Compliance Coordinator and DON unaware of the deficiencies in tracking and documentation.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours per day, seven days a week, as required. Review of the Payroll Based Journal (PBJ) reports for the federal fiscal third and fourth quarters of 2025 showed days without the required RN coverage. Daily census posting sheets from April through September 2025 documented a consistent census of fewer than 60 residents and confirmed that on multiple specific dates there was no RN coverage for eight consecutive hours. Daily nursing staffing sheets for the same period also showed that no RN was scheduled for at least eight consecutive hours on those dates, and timecard records confirmed that no RN actually worked eight consecutive hours on those days. During an interview, the Administrator stated she was responsible for ensuring that an RN was scheduled to work eight consecutive hours each day and acknowledged ongoing difficulties in maintaining this required coverage since she began her role. She reported that the facility relied on agency nurses to fill RN shifts, and when an agency RN did not report for a scheduled shift, she was often unable to secure a replacement. She also noted that the previous Director of Nursing was unavailable during these times, which contributed to the gaps in the required RN coverage.
Failure to Obtain Informed Consent for Psychotropic Antidepressant Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent prior to initiating psychotropic antidepressant medications for seven residents reviewed for unnecessary medications. For each of these residents, physician orders were in place for various antidepressants, including duloxetine, sertraline, amitriptyline, trazodone, bupropion, and Prozac, and the Medication Administration Records (MARs) showed that the medications were administered as ordered. However, the electronic medical records (EMRs) contained no documentation that the residents or their responsible parties were informed in advance of the name and purpose of the medications, the risks and benefits, alternatives, or the right to refuse, and there were no signed informed consent forms or progress notes reflecting informed consent discussions. One resident admitted with depression had an order for duloxetine 30 mg twice daily, was documented as cognitively intact on the MDS, and received the antidepressant in February and March, but there was no record of informed consent. Another resident with stroke and depression had orders for sertraline 75 mg at bedtime and later amitriptyline 25 mg at bedtime for insomnia; the resident had mild cognitive impairment and received these medications, yet the EMR lacked any documentation of informed consent for either psychotropic medication. A third resident with stroke and depression, cognitively intact per MDS, received sertraline 150 mg daily and later 100 mg daily over several months, with MARs confirming administration, but again without any EMR documentation that risks and benefits were discussed or consent obtained. Additional residents were similarly affected. One cognitively intact resident with major depressive disorder, anxiety, falls, and muscle weakness had new orders for trazodone 50 mg at bedtime as needed for insomnia and bupropion SR 150 mg daily for depression, and received both medications, but there was no documentation of informed consent. Another cognitively intact resident with dementia and insomnia continued trazodone 50 mg at bedtime, and two cognitively intact residents with major depression received Prozac 10 mg daily and duloxetine 20 mg twice daily, respectively; in all three cases, MARs confirmed ongoing administration, but EMRs lacked any evidence that the residents or responsible parties were informed about the medications, including their purpose, risks, benefits, alternatives, or right to refuse, and there were no signed consent forms or progress notes documenting such discussions. Interviews with the Case Manager and DON confirmed they were not aware that consent was required for psychotropic medications and that the facility had not been obtaining informed consent prior to initiation, and the Physician stated she was unaware consent had not been obtained and that obtaining informed consent prior to initiating psychotropic medications was essential.
Failure to Discard Expired Food Items in Kitchen Refrigerator
Penalty
Summary
Surveyors observed that kitchen staff failed to discard multiple expired food items stored in one of two reach-in refrigerators, contrary to professional standards and facility expectations for food safety. During an initial kitchen tour on 03/22/26 at 10:20 AM with a staff member identified as #1, surveyors found an opened plastic container of sauerkraut with a discard date of 2/24/26, an opened plastic container of canned pears with a discard date of 3/12/26, an opened plastic container of canned tuna with a discard date of 3/19/26, and an opened plastic container of canned pork and beans with a discard date of 3/21/26 still stored in the refrigerator. In an interview at 10:25 AM on 03/22/26, the weekend cook (staff #1) stated that all kitchen staff were responsible for checking and discarding expired foods, acknowledged he had not checked the refrigerator that morning, and confirmed he had also worked the previous day when the expired items were overlooked. In a 03/24/26 interview at 12:42 PM, the Dietary Manager stated that perishable foods were to be discarded after 3 days and that staff should have removed the foods on their discard dates, and in a separate interview at 12:52 PM the Administrator stated she expected kitchen staff to check for expired foods daily and remove any foods by the discard date.
Failure to Notify Physician of Multiple Missed Antibiotic Doses
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician when a resident missed multiple ordered doses of an antibiotic. The resident was admitted with diagnoses including chronic osteomyelitis and diabetes and had a physician’s order dated 2/13/26 for doxycycline 100 mg by mouth twice daily indefinitely for chronic osteomyelitis. Review of the March 2026 MAR showed that on 3/9/26, both the lunch and evening doses were documented as not administered due to the medication being unavailable, with no corresponding documentation in the nursing progress notes that the physician was notified. On 3/10/26, the lunch dose was again documented as not administered because the medication was unavailable, and the evening dose was not given while staff documented they were waiting for pharmacy delivery, with no evidence of physician notification. Further review showed that on 3/11/26, both the lunch and evening doses were not administered due to the medication being unavailable or awaiting pharmacy refill, and on 3/12/26, both the lunch and evening doses were also not administered because the medication was unavailable. In total, eight doses of doxycycline were missed without physician notification. Interviews with multiple nurses confirmed they did not inform the physician when the antibiotic was unavailable and not administered, with some nurses stating they did not think it was necessary or did not realize notification was required. The DON stated she expected medications to be administered as ordered and that staff should notify the provider when a medication is not available. The physician reported being unaware that the resident had missed eight doses of the prescribed antibiotic and stated that medications should be available and administered as ordered, and that the provider should be notified if a medication is not available.
Failure to Obtain and Administer Ordered Antibiotic Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide prescribed pharmaceutical services by not obtaining and administering doxycycline 100 mg twice daily as ordered for a resident with chronic osteomyelitis and diabetes. A physician order dated 2/13/26 directed that the resident receive doxycycline 100 mg by mouth twice per day indefinitely for chronic osteomyelitis. Review of the March 2026 MAR showed that eight consecutive doses of doxycycline were not administered on 3/9/26, 3/10/26, 3/11/26, and 3/12/26, with nurses documenting that the medication was unavailable, awaiting pharmacy delivery, or awaiting pharmacy refill. The physician later stated she was unaware that eight doses had been missed and indicated that medications should be available and administered as ordered. On 3/9/26, the nurse assigned from 7:00 AM to 7:00 PM documented that the lunch dose was not given because the medication was unavailable in the resident’s medication cabinet and acknowledged she did not check the automated medication dispensing machine or contact the pharmacy or local backup pharmacy. Another nurse documented the evening dose on 3/9/26 as unavailable and not administered. On 3/10/26, one nurse documented the lunch dose as unavailable and not administered, and another nurse documented the evening dose as waiting for pharmacy delivery and not administered. On 3/11/26, the day nurse documented the lunch dose as unavailable and awaiting pharmacy refill, and reported that she did not check the automated dispensing machine or contact the pharmacy, assuming the medication would arrive later. On the nights of 3/11/26 and 3/12/26, the night nurse reported that the doxycycline was not in the resident’s medication cabinet and that, although she checked the automated dispensing machine, the correct dose was not available there. She acknowledged that she did not contact the pharmacy on 3/11/26 and, when she did call on 3/12/26, she did not request that the medication be sent through the backup system and did not report the discrepancy in dosing frequency between the pharmacy’s once-daily entry and the facility’s twice-daily order to the DON or physician. The DON stated she expected medications to be administered as ordered and that nurses should notify the pharmacy and use the automated dispensing machine and local backup pharmacy when medications were not available. The Pharmacy Manager reported that the pharmacy had systems for daily availability, including twice-daily deliveries and backup processes, and stated that if notified, the doxycycline would have been sent through the backup system; he also confirmed the pharmacy had entered the order as once daily instead of twice daily and acknowledged the potential risk for worsening of the infection due to the missed doses.
Failure to Implement Pharmacist-Recommended Change in Hydroxyzine Dosing
Penalty
Summary
The deficiency involves the facility’s failure to act on a Consultant Pharmacist’s monthly medication regimen review and update a resident’s hydroxyzine order in the electronic medical record after the physician had signed to change the order. Resident #8, admitted with diagnoses including pruritus, had a physician’s order dated 7/10/23 for hydroxyzine 25 mg three times a day for pruritus. The Consultant Pharmacist’s Medication Regimen Review dated 1/12/26 documented that on 12/12/25 the physician signed the pharmacy consult report to change the hydroxyzine to 25 mg every morning and midday and discontinue the three-times-daily dosing. However, this new order was not entered into the electronic medical record. Review of the Medication Administration Record from 12/12/25 through 1/18/26 showed that Resident #8 continued to receive hydroxyzine 25 mg three times a day, as evidenced by nursing signatures, indicating the original order remained in effect despite the physician-approved change. The Director of Nursing reported that the Consultant Pharmacist emailed monthly medication regimen reviews and described a process in which physician recommendations from these reviews were to be placed in a physician’s notebook and, once signed, entered into the electronic record. The DON stated she was new to the facility in December 2025 and did not promptly address the December pharmacy reports, resulting in a delay in implementing the reduced hydroxyzine dosing until the Consultant Pharmacist notified her the following month that the frequency had not been changed. The Clinical Compliance Administrator confirmed that medication regimen reviews were expected to be addressed as soon as the DON received them.
Multiple Medication Administration and Order-Entry Errors Affecting Three Residents
Penalty
Summary
The deficiency involves multiple significant medication errors affecting three residents. One resident with chronic osteomyelitis and diabetes had a physician order dated 2/13/26 for doxycycline 100 mg by mouth twice daily indefinitely. Review of the March 2026 MAR showed that eight consecutive doses of doxycycline, both midday and evening, were not administered over four days, with nurses documenting that the medication was unavailable, awaiting pharmacy delivery, or awaiting refill. Several nurses who were assigned to the resident during this period acknowledged that the ordered antibiotic was not given and reported that they did not contact the pharmacy to obtain the medication, or only did so after multiple missed doses. The physician later stated she had been unaware that eight doses were missed and characterized the failure to administer the prescribed antibiotic as a significant medication error. A second deficiency involved a resident admitted with major depression and Parkinson’s disease. The hospital discharge summary ordered mirtazapine 15 mg, one-half tablet by mouth at 11:00 PM. However, on 2/27/26 the DON entered an order in the electronic record for mirtazapine 15 mg by mouth at bedtime, resulting in the resident receiving a full 15 mg tablet nightly instead of the intended 7.5 mg dose. The MAR from 2/27/26 through 3/10/26 showed that 15 mg doses were administered each night, and there was no documentation during that period of any clarification or correction of the dose by the prescriber. The DON later stated she had transcribed the order incorrectly and that the facility’s two-step verification process for new orders was not completed for this medication. A third deficiency concerned a resident admitted with pruritus who had a physician’s order dated 7/10/23 for hydroxyzine 25 mg three times daily. A consultant pharmacist’s medication regimen review dated 1/12/26 noted that the physician had signed a prior pharmacy consult report from 12/12/25 to change the hydroxyzine to 25 mg every morning and midday and discontinue the three-times-daily schedule, and requested that the electronic record be corrected and the medication error reported. Despite this, the MAR from 12/12/25 through 1/18/26 showed the resident continued to receive hydroxyzine 25 mg three times daily. The physician’s order in the electronic record was not updated to twice daily until 1/19/26. The DON stated she was new to the role, received the monthly pharmacist reviews, and did not promptly address the December report, resulting in the resident continuing on the higher frequency dosing until the order was finally changed. Across these three cases, surveyors identified failures in ensuring medications were available and administered as ordered, accurate transcription of physician orders, and timely implementation of pharmacist-recommended order changes. The pharmacy manager stated that the pharmacy had systems for daily medication availability and backup processes, and acknowledged the potential risk associated with missing multiple doses of an antibiotic. The DON stated she expected medications to be administered as ordered and that nursing staff should contact the pharmacy when medications were not available, but in these instances, staff either did not contact the pharmacy in a timely manner or did not correct orders in the electronic record, leading to prolonged deviations from prescribed regimens.
Failure to Develop and Implement Fall Risk Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans addressing fall risk for two residents who had documented histories of falls and related diagnoses. For the first resident, who was cognitively intact and had a left knee fracture, the Minimum Data Set (MDS) admission assessment triggered the need for a fall risk care plan, but none was created. This resident experienced multiple falls during their stay, as documented in nursing progress notes and event reports, yet the care plan was not updated to address fall risk. The MDS Nurse confirmed that the care area assessment for falls was triggered and acknowledged that a fall risk care plan should have been initiated but was missed. The MDS Nurse also did not attend weekly interdisciplinary team (IDT) meetings where care plans were to be reviewed and updated, and the Interim Director of Nursing (DON) confirmed that the care plan should have been updated during these meetings. Similarly, the second resident, who had severe cognitive impairment and a history of falls, also did not have a fall risk care plan in place despite the MDS assessment triggering the need for one. This resident experienced several falls during their stay, as documented in nursing progress notes. The MDS Nurse again confirmed that the fall risk care plan was not developed as required and stated it was missed. The Interim DON reiterated that the care plan should have been updated during weekly IDT meetings, but the MDS Nurse's absence from these meetings contributed to the deficiency. The Administrator confirmed that the MDS Nurse was responsible for developing the fall risk care plans for both residents.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement a comprehensive system to monitor antibiotic use, as required by their Antibiotic Stewardship Program policy. This deficiency was evident over a 12-month period from January 2024 to December 2024, affecting all 18 residents in the facility. The monthly antibiotic summary reports reviewed did not include necessary information such as surveillance logs, microbiology testing results, or trends in infection, nor did they document the antibiotics ordered. The facility's policy, last revised in February 2023, required the review of essential data including antibiotic orders and infection trends, which was not adhered to. Interviews with facility staff revealed a lack of oversight and responsibility for the antibiotic stewardship program. The Compliance Coordinator, who was SPICE trained and responsible for overseeing the Infection Control Program, was unaware that the previous Infection Preventionist had not completed the necessary surveillance or tracking of infections. The Director of Nursing, who assumed the role of Infection Preventionist in December 2024, acknowledged receiving a list of antibiotics from the pharmacy but had not documented antibiotic use or tracked infections. The interim Administrator, in position since January 2025, recognized the need for a comprehensive infection control program but was unaware of the reasons for the lack of tracking and trending of infections and antibiotic use prior to her tenure.
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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) |
|---|---|---|---|---|
| Davis Health Care Center | 3.1 mi | ★★★★★ | 1 | 1 |
| Northchase Nursing And Rehabilitation Center | 3.4 mi | ★★★★★ | 0 | 0 |
| Liberty Commons Rehabilitation Center | 3.4 mi | ★★★★★ | 3 | 0 |
| Bradley Creek Health Center | 3.5 mi | ★★★★★ | 0 | 0 |
| Cypress Pointe Rehabilitation Center | 7.6 mi | ★★★★★ | 1 | 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.