Below 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 Davis Health Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and blindness was left unsupervised in a wheelchair near a lit fireplace, resulting in a fall and contact with the hot surface. The resident sustained second-degree burns and a head injury. The facility lacked safety barriers and staff training regarding fireplace hazards, and the fireplace controls were accessible to residents, contributing to the incident.
The facility did not ensure that the time between the evening meal and breakfast the next day was within the required 14-hour window, with meal service intervals reaching up to 17 hours. Staff and residents reported that substantial evening snacks were no longer routinely provided, and residents experienced hunger due to the extended gap between meals. Facility leadership and the RD acknowledged the deficiency and the absence of a process to address the issue.
For a period of ten months, the facility did not document or communicate resolutions to concerns raised by residents during Resident Council meetings, including issues such as missed showers, staff using headphones during care, delayed call light responses, and late meal service. Residents reported that their grievances were not discussed or resolved in subsequent meetings, and interviews confirmed that these concerns persisted without follow-up or feedback from staff.
The facility did not update or coordinate care plans with the Hospice provider for two residents with severe cognitive impairments and multiple diagnoses who had elected Hospice services. Despite proper election of Hospice benefits and ongoing services, the facility's care plans lacked documentation of Hospice interventions, as confirmed by interviews with the DON, MDS nurses, and Hospice staff.
The facility did not transmit annual and discharge MDS assessments to CMS within the required 14-day period for four residents. This occurred due to recent staff changes in the MDS department, with new nurses still in training and the DON overseeing the process. Assessments were completed but not sent, as confirmed by record review and staff interviews.
Failure to Supervise and Protect Resident from Environmental Hazard Resulting in Severe Burns
Penalty
Summary
A deficiency occurred when staff failed to identify and mitigate an environmental hazard and provide adequate supervision for a newly admitted resident who was severely cognitively impaired and blind. The resident, who had a history of vascular dementia, frequent falls, and glaucoma, was placed in his wheelchair near a lit fireplace in the dining room after expressing that he felt cold. The nurse aide assigned to him left the resident unsupervised to assist another staff member, leaving the resident alone in close proximity to the hot fireplace. While unattended, the resident tipped his wheelchair backward, falling against the fireplace. His head, back, and shoulders came into contact with the hot mesh grate, resulting in second-degree burns with blistering to the back of his scalp, right shoulder, upper back, and left index finger, as well as a hematoma to the back of his head. The resident experienced severe pain, required emergency medical services, and was hospitalized for wound care and pain management. The incident was witnessed by another resident, who called for help, and staff responded after hearing the resident's cries. The facility lacked safety precautions to prevent residents from accessing or activating the fireplaces or coming into contact with the hot surfaces. There were no physical barriers, safety gates, or lockout features on the fireplaces, and staff had not received training or education regarding fireplace safety. The operational switches for the fireplaces were accessible to residents, and staff and residents were observed to regularly turn the fireplaces on and off. The environmental hazard was not recognized or addressed prior to the incident, and the resident was left unsupervised despite being identified as a high fall risk and having significant cognitive and visual impairments.
Removal Plan
- Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
Failure to Maintain Required Interval Between Dinner and Breakfast Meals
Penalty
Summary
The facility failed to ensure that the lapse between the evening meal and breakfast the following day did not exceed 14 hours, as required. Observations and interviews revealed that meal carts for several areas were delivered for dinner as early as 4:30 PM and breakfast as late as 9:30 AM, resulting in time spans of 15 to 17 hours between meals. Staff interviews confirmed that breakfast was typically served between 8:15 AM and 9:30 AM, and the dinner meal was served as early as 4:30 PM, leading to extended periods without substantial food. Residents and staff reported that the long interval between dinner and breakfast left residents hungry in the morning. One resident specifically stated that the time between dinner and breakfast was too long and that she was very hungry by breakfast. Staff also noted that the facility no longer provided substantial evening snacks, such as sandwiches, and instead only offered small items like crackers or fruit cups if requested. The Director of Dining Services, Certified Dietary Manager, and Registered Dietitian all acknowledged that the current meal schedule did not meet the regulatory requirement of no more than 14 hours between the evening meal and breakfast, and that a nourishing snack should be provided if this interval is exceeded. The Compliance Coordinator indicated that the issue of meal timing had been discussed in Quality Assurance meetings, but no solution had been implemented to ensure compliance. The Registered Dietitian confirmed that the facility was not meeting the requirement to provide a nourishing snack when the interval between dinner and breakfast exceeded 14 hours. The lack of a process to ensure timely meal service and the discontinuation of substantial evening snacks contributed directly to the deficiency.
Failure to Address and Communicate Resolutions to Resident Council Grievances
Penalty
Summary
The facility failed to address and communicate resolutions to grievances reported during Resident Council meetings for 10 out of 12 months reviewed. Review of Resident Council meeting minutes from April 2024 through March 2025 showed that concerns raised by residents, such as missed scheduled showers, staff using headphones or cell phones during care, delayed response to call lights, and issues with meal timeliness, were repeatedly documented without any follow-up or discussion of resolutions in subsequent meetings. The minutes consistently lacked documentation of how previous concerns were addressed, and residents reported that their ongoing issues were not being discussed or resolved at the start of each meeting. Interviews with residents confirmed that their concerns had persisted for months without resolution or feedback from facility staff. The newly hired Activities Director and the Administrator, both of whom started their roles recently, were unaware of how previous concerns had been managed and had no documentation to show that grievances were addressed. Residents continued to experience the same issues, including late breakfast service, unfulfilled shower schedules, delayed call light responses, and staff using headphones during care, indicating a pattern of unaddressed resident grievances over an extended period.
Failure to Coordinate and Document Hospice Care Plans
Penalty
Summary
The facility failed to coordinate and document a plan of care with the Hospice provider for two residents who had elected Hospice services. Both residents had significant cognitive impairments and multiple medical diagnoses, including dementia, malnutrition, and chronic pain. Although the residents' responsible parties had signed the Election of Hospice Benefit forms and Hospice care was indicated in their Minimum Data Set (MDS) assessments, the facility's care plans did not reflect that the residents were receiving Hospice services. Review of the electronic care plan records showed no current Hospice plan of care, only progress notes from Hospice. Interviews with the Director of Nursing (DON), MDS nurses, Clinical Compliance Administrator, and the Hospice Nurse confirmed that the facility's care plans were not updated to include Hospice interventions or documentation. The DON acknowledged that the process for obtaining and coordinating a Hospice care plan was not followed, and that the MDS nurses had overlooked updating the care plans. The Hospice Nurse stated that she provided all necessary documentation to the facility, but was unaware that the care plans had not been updated. Both the DON and Administrator confirmed that Hospice information should have been included in the facility's care plans for these residents, but it was not.
Failure to Transmit MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to transmit required Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) system within the mandated 14-day timeframe for four residents. Specifically, annual MDS assessments for three residents and a discharge MDS assessment for one resident were either marked as finalized or in production batch status, indicating that they were completed but not transmitted or not sent at all. These findings were based on record review and staff interviews, which confirmed that the assessments were not submitted as required. During an interview, the Director of Nursing (DON) explained that she was new to her position and that all MDS nurses were also new and still undergoing training. The DON acknowledged responsibility for managing and coordinating the assessments and stated that the delays in transmission were due to recent personnel changes in the MDS department. The DON clarified the status terms used in the system and confirmed that the assessments had not been transmitted within the regulatory timeframe.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 62 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 And Wellness Center At Cambridge Vill | 3.1 mi | ★★★★★ | 8 | 0 |
| Northchase Nursing And Rehabilitation Center | 6 mi | ★★★★★ | 0 | 0 |
| Bradley Creek Health Center | 6 mi | ★★★★★ | 0 | 0 |
| Liberty Commons Rehabilitation Center | 6.2 mi | ★★★★★ | 3 | 0 |
| Woodbury Wellness Center Inc | 10.3 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Davis Health Care Center.
100% money-back within 48 hours.
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.