Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wilmington Nursing & Rehab during CMS and state inspections, most recent first.
Unsanitary food handling was observed during breakfast tray prep when an employee handled bacon with gloved hands instead of tongs and then touched paper slips, trays, plates, and doughnut wrappers with the same gloves while continuing to handle the bacon. The employee confirmed tongs were not used and said the gloves should have been changed after touching other items. The DON confirmed gloves should be worn when preparing plates with bacon, and facility policy required utensils and clean tongs to avoid manual contact with prepared foods.
Medication administration errors resulted in a 10% error rate, exceeding the 5% threshold. During observed med passes, an RN gave an incorrect memantine dose to one resident, another resident received only one cimetidine tablet instead of two, and a third resident received only one furosemide tablet instead of two. The facility policy required staff to verify the correct medication and dose each time a med was given.
The facility failed to maintain an effective infection control program. A resident with an indwelling urinary catheter had orders and a care plan for EBP, but staff did not know what EBP meant and no signage or PPE was in place. A CNA then used dirty gloves and gown after catheter care to touch another resident’s recliner and pillows, and a treatment cart trash can held dirty PPE without a lid. An RN also picked up dropped meds with bare hands during med prep for a resident.
Improper incontinence care was observed for a resident with severe cognitive impairment who was dependent on staff for all ADLs and always incontinent of bowel and bladder. A CNA provided peri care using only water, did not perform hand hygiene before care, and kept the same gloves on throughout the task before washing hands afterward. The CNA confirmed soap was not used and the facility policy required hand hygiene prior to incontinent care and use of soap or a no-rinse cleanser.
Failure to provide timely pain management for a resident with a traumatic amputation and other chronic conditions. The resident reported severe left leg pain and stated she had only received Tylenol, while the ordered oxycodone/acetaminophen was not available in the cart or Omnicell. RN did not contact the physician for an alternate pain medication or provide pain interventions, and a scheduled Tylenol dose was also not given on time.
Medication administration errors occurred when one resident did not receive a scheduled Tylenol dose for pain management and another resident received only half of the ordered furosemide dose. The RN initially did not see the Tylenol order, later confirmed the missed dose, and also verified the furosemide order was for two tablets but only one was administered. The DON stated nurses were expected to give medications timely and per physician order.
Unlabeled medication cups were prepared for two residents at the same time and carried into their room for administration. The RN confirmed the cups had no identifiers and contained separate medication sets for each resident, while the DON stated nurses were not expected to pass meds to several residents at the same time. One resident had urinary and prostate-related diagnoses, and the other had DM2, hemiplegia, vascular dementia, and adult failure to thrive.
Smoking Near Oxygen Cylinder: A resident who was cognitively intact, had COPD, and was ordered continuous O2 was observed smoking outside with an O2 cylinder on the back of the wheelchair while a visitor was present. The DON verified the cylinder was attached, a progress note documented the resident had a lit cigarette beside the O2 cylinder, and staff interviews confirmed the resident routinely went out to smoke with the oxygen tank on the wheelchair despite the facility smoking policy prohibiting smoking near oxygen.
Failure to provide dental services for a resident with a broken tooth. A cognitively intact resident with diagnoses including bladder cancer, severe malnutrition, hyponatremia, and anxiety was observed with a chipped tooth, while the MDS showed no oral issues and the order allowed dental visits PRN. The SSD said the resident was not seen at the last dental visit and no residents were scheduled for the next visit, and the DON confirmed the resident appeared to need dental work. The resident stated he needed a root canal.
The facility failed to serve food at a warm and palatable temperature, affecting nearly all residents. Observations revealed that while initial cooking temperatures were adequate, the food was served cold and bland. Residents confirmed the food was overcooked and unappetizing, contrary to the facility's food preparation policy.
The facility failed to conduct quarterly care conferences for several residents, contrary to its policy. A resident with type two diabetes and COPD had only two care conferences in a year, while another with Parkinson's disease had just one. Two other residents, one with cerebral infarction and another with multiple diagnoses, also did not receive the required quarterly care conferences. Interviews confirmed these deficiencies.
A resident with diabetes and moderate cognitive impairment did not receive timely foot care due to missed and canceled podiatry appointments. The resident's toenails became overgrown and curling, with dry and peeling skin. Staff interviews confirmed the failure to ensure timely podiatry services, despite the facility's policy requiring follow-up for ancillary services.
A resident with severe cognitive impairment was affected by a significant medication error when they were administered incorrect doses of Warfarin on multiple occasions. Despite physician orders specifying different dosages for different days, the resident received both five mg and six mg doses on eight days due to incorrect entries in the MAR. The error was confirmed by the DON, highlighting a failure to adhere to the facility's medication administration policy.
The facility did not deliver mail to residents on weekends, affecting all 63 residents. Interviews revealed that mail was only distributed Monday through Friday, despite the Business Office Manager stating that mail should be delivered on Saturdays, except for insurance-related mail. The Activities Director confirmed the lack of Saturday mail delivery. The resident rights handbook indicated that residents have the right to receive mail with privacy and access to necessary materials.
Unsanitary Food Handling During Tray Preparation
Penalty
Summary
Food was not distributed under sanitary conditions during breakfast tray preparation. During observation on 06/09/2026 from 7:33 A.M. to 7:43 A.M., [NAME] #230 was preparing bacon for residents' meal trays by grabbing the bacon with gloved hands and no tongs. While continuing to handle the bacon with the same gloves, [NAME] #230 also touched paper slips, trays, plates, and plastic wrappers containing doughnuts. During the observation, [NAME] #230 confirmed that tongs were not being used to prepare the bacon and stated the gloves should have been changed after touching other items and surfaces. [NAME] #230 also stated the kitchen only had two tongs and she did not use them for the bacon. The Dietary Manager #226 confirmed that gloves should be worn when preparing plates with bacon for residents. Facility policies stated to use utensils to handle food whenever possible and to serve food with clean tongs to avoid manual contact of prepared foods.
Medication error rate exceeded 5% during observed medication passes
Penalty
Summary
The facility failed to ensure medications were administered with a medication error rate of less than 5%, based on observation, record review, interview, and facility policy. Surveyors observed 29 medication opportunities and identified 3 errors, resulting in a 10% error rate. The deficiency involved three residents and was documented during medication administration observations with two RNs. For one resident with dementia, peripheral vascular disease, and Alzheimer’s disease, the physician order was for memantine 5 mg, two tablets twice daily, but the RN administered two tablets of memantine 10 mg for a total of 20 mg and confirmed the medication card labeled memantine 10 mg one tablet. For another resident with Parkinson’s disease with dyskinesia and moderate protein calorie malnutrition, the order was for cimetidine 200 mg, two tablets daily, but only one tablet was administered. For a third resident with type 2 diabetes, morbid obesity, anemia, and depression, the order was for furosemide 20 mg, two tablets daily, but only one tablet was administered during the observed medication pass. The facility policy titled General Dose Preparation and Medication Administration required staff to verify the correct medication, dose, route, rate, time, and resident each time a medication was given.
Infection Control and Medication Handling Failures
Penalty
Summary
The facility failed to maintain an effective infection control program. Resident #8 had diagnoses including malignant neoplasm of the bladder, severe protein-calorie malnutrition, hyponatremia, and anxiety disorder. The resident’s record showed an order for isolation/transmission-based precautions for an indwelling urinary catheter and a care plan identifying infection control risk with enhanced barrier precautions (EBP) for the catheter. However, RN #301 stated she was not sure what EBP meant, RN #274 confirmed there was no sign, PPE, or EBP in place for the resident, the DON verified no EBP were in place, and CNA #300 stated no EBP had been used for the resident’s personal care. Resident #13 had diagnoses including obstructive and reflux uropathy, neuromuscular dysfunction of the bladder, benign prostatic hyperplasia with lower urinary tract symptoms, and urinary retention. During suprapubic catheter care, CNA #252 wore gloves and then left Resident #13’s side of the room and went to Resident #55’s side while still wearing dirty gloves and gown. She used those dirty gloves to touch Resident #55’s recliner and two pillows while looking for trash bags. CNA #252 confirmed this was cross contamination and stated she should have disposed of the dirty PPE and performed hand hygiene before touching another resident’s property. On the A Hall treatment cart, the trash can had no lid and contained blue gowns and gloves. RN #271 confirmed the trash can had no lid and that the items in it were dirty PPE that should have had a lid on them. In addition, while preparing medication for Resident #62, RN #273 dropped glipizide ER and Jardiance 25 mg onto the medication cart and into a drawer, then picked up both pills with bare hands and placed them into the medication cup. RN #273 confirmed she used her bare hands to pick up the pills, and the DON stated nurses were expected to administer medication that was not dropped or touched with hands and to use hygiene when preparing medication.
Improper Incontinence Care and Hand Hygiene
Penalty
Summary
The facility failed to provide proper incontinence care for one resident reviewed for incontinence care. Resident #48 was admitted with diagnoses including Alzheimer's disease, muscle weakness, and radiculopathy of the lumbar region. The MDS assessment showed severely impaired cognition, dependence on staff for all ADLs, and that the resident was always incontinent of bowel and bladder. During observation, CNA #260 donned a gown and gloves, placed clean washcloths in the resident's sink, and turned on the water. The CNA then removed the resident's covers and clothing with the same gloves and began incontinence care. The resident's peri area was cleaned with washcloths using only water, then dried with clean, dry washcloths. After the brief was applied and the resident was repositioned with RN #265, the CNA kept the same gloves on, turned on the sink faucet, removed the gloves, and then washed hands. In interview, the CNA confirmed hand hygiene was not performed before care, soap was not applied to the washcloths, and only water was used. Facility policy stated staff are to have a basin and soap or a no-rinse incontinent cleanser and perform hand hygiene prior to incontinent care.
Failure to Provide Timely Pain Medication
Penalty
Summary
The facility failed to provide timely pain management for one resident who was admitted with diagnoses including complete traumatic amputation of the hip and knee, peripheral vascular disease, type 2 diabetes, and an abdominal hernia without obstruction or gangrene. The resident had physician orders for routine Tylenol 325 mg, two tablets every six hours, and oxycodone/acetaminophen 10-325 mg every six hours as needed. Review of the medication administration record showed the scheduled Tylenol due at 12:00 P.M. was not administered, and the resident’s pain assessment for the day shift was documented as zero despite later reporting significant pain. During observation and interview, the resident was sitting in a wheelchair, groaning, and stated she had a lot of pain in her left leg from the amputation and rated her pain as eight out of 10. The resident reported she had not received oxycodone/acetaminophen at the facility and had only been given Tylenol, and that staff had told her the medication was being ordered. RN #301 confirmed the resident reported pain earlier in the day, that she called the pharmacy several times, and that she did not contact the physician for an alternate medication or provide any pain interventions. The DON later verified there was no oxycodone/acetaminophen in the Omnicell, that other pain medications were available, and that the nurse should have called the physician when the ordered medication was unavailable and the resident was reporting pain.
Medication Administration Errors
Penalty
Summary
The facility failed to be free from significant medication errors for a resident with an order for Tylenol 325 mg, two tablets every six hours routinely. The resident, who had a complete traumatic amputation of the hip and knee, peripheral vascular disease, type 2 diabetes, and an abdominal hernia without obstruction or gangrene, was admitted on 06/08/26 at 11:30 P.M. Review of the physician orders showed Tylenol was scheduled for 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M., but the medication administration record showed the 12:00 P.M. dose was not given. During interview, the resident stated she had a lot of pain in her left leg from the amputation, said the last pain medication she received was the prior night, and reported her pain was 8 out of 10. The RN stated she did not see an order for Tylenol at first, then later confirmed the resident did not receive the 12:00 P.M. dose. The DON stated nurses were expected to administer medication timely and per physician order to manage pain. The facility also failed to administer medication within the ordered dose for another resident. A resident with diagnoses including type 2 diabetes, morbid obesity, anemia, and depression had an order for furosemide 20 mg, two tablets every day. During observation of medication administration, the resident received only one tablet of furosemide instead of the ordered two tablets. The RN later verified that only one tablet had been given and confirmed the physician order was for two tablets. The report also cites the facility policy requiring staff to verify the correct medication, dose, time, and resident before administration.
Unlabeled medication cups taken to two residents at once
Penalty
Summary
The facility failed to follow acceptable standards of practice when a nurse prepared medications for two residents at the same time and took both unmarked medication cups into the residents’ room for administration. During observation, the nurse was standing at the medication cart holding two unlabeled cups with unknown pills inside, with no room number, initials, or names on either cup to identify which resident each set of medications belonged to. The nurse confirmed that one cup contained medications for one resident and the other cup contained medications for the second resident, and then carried both cups into the room shared by the two residents to give the medications. Resident #13 had diagnoses including obstructive and reflux uropathy, neuromuscular dysfunction of the bladder, benign prostatic hyperplasia with lower urinary tract symptoms, and urine retention. Resident #55 had diagnoses including type 2 diabetes, hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, vascular dementia, and adult failure to thrive. The nurse stated that delivering medications simultaneously to two residents was not the facility practice and was unsafe, and the DON stated that nurses were expected not to administer medication to two residents at the same time and that it was not the facility practice to pass medication to several residents at the same time.
Smoking Near Oxygen Cylinder
Penalty
Summary
The facility failed to ensure a resident who was identified as a smoker and who was receiving continuous oxygen therapy was not smoking near an oxygen tank. Resident #32 had diagnoses including chronic obstructive pulmonary disease, chronic kidney disease stage three, and anxiety disorder, and the most recent MDS indicated the resident was cognitively intact and receiving oxygen therapy. The care plan identified the resident as an unsupervised smoker who was to enjoy tobacco safely in accordance with policy, and physician orders directed oxygen via nasal cannula continuously at 3 liters per minute. During observation, Resident #32 was seen outside in front of the building smoking with a visitor while the oxygen cylinder was on the back of the wheelchair. The DON verified the oxygen was on the wheelchair and removed the tank. A DON progress note documented the resident sitting in the front parking lot with a lit cigarette and an O2 cylinder on the wheelchair, and the resident stated she usually removes it but forgot and that the nurse should have reminded her. Interviews with staff confirmed that Resident #32 routinely went out to smoke with the oxygen tank on the back of the wheelchair, and the facility smoking policy stated that no smoking may occur near oxygen or other combustible materials.
Failure to Provide Dental Services for Resident with Broken Tooth
Penalty
Summary
The facility failed to ensure dental services were provided for a resident with a broken tooth. Resident #8 was admitted with diagnoses including malignant neoplasm of the bladder, severe protein-calorie malnutrition, hypo-osmolality and hyponatremia, and anxiety disorder. The most recent MDS assessment identified the resident as cognitively intact and marked no dental issues. Provider orders dated 04/01/26 stated the resident may see a dentist as needed. On 06/08/2026, observation revealed Resident #8 had a broken tooth. During interview, the Social Service Designee stated the dental provider sends a list of residents to be seen and social services adds any additional residents needing dental care, but Resident #8 was not seen at the last dental visit and no residents were scheduled for the upcoming visit. The DON confirmed the resident had a chipped tooth and appeared to need dental work, and stated the oral issue should have been documented in the resident's record. The resident stated he needed a root canal. The facility policy stated social services is responsible for coordinating needed ancillary dental services and ensuring referrals are made when needed.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food was served at a warm and palatable temperature, affecting all residents except one who did not receive food from the facility's kitchen. During an observation of the meal service, it was noted that the cooking temperatures of the fish patty, chicken fingers, and broccoli casserole were initially within safe ranges. However, by the time the food was served to residents, the temperatures had significantly dropped, rendering the food unsatisfactory in terms of temperature and taste. The surveyor's test tray confirmed that the food items were not hot and were bland in taste, with an unappealing presentation. Interviews with several residents corroborated the surveyor's findings, as they reported that the fish and chicken were overcooked, resulting in hard breading and dry meat, while the broccoli casserole was dry and lacked flavor. The facility's policy on food preparation and handling, which was reviewed, emphasized maintaining safe temperatures and enhancing flavor, but these standards were not met during the observed meal service. This deficiency was investigated under Complaint Number OH00160920.
Failure to Conduct Quarterly Care Conferences
Penalty
Summary
The facility failed to conduct quarterly care conferences for residents, as required by their Comprehensive Care Planning Policy. This deficiency affected four out of five residents reviewed, with the facility having a census of 63. Resident #18, diagnosed with type two diabetes mellitus, COPD, convulsions, and anxiety disorder, had only two care conferences in the last 12 months, despite having moderate cognitive impairment. Similarly, Resident #21, with diagnoses including Parkinson's disease and emphysema, had only one care conference in the past year, even though their cognition was intact. Resident #52, who had cerebral infarction and congestive heart failure, also received only one care conference in the last year, despite having intact cognition. Resident #29, with multiple diagnoses including cerebral infarction and type two diabetes mellitus, had only two care conferences in the past year. Interviews with the Social Services Designee confirmed the lack of quarterly care conferences for these residents, which is contrary to the facility's policy that mandates a comprehensive care plan to be reviewed and updated at least every 90 days.
Failure to Provide Timely Foot Care
Penalty
Summary
The facility failed to provide timely foot care for a resident, leading to a deficiency in care. The resident, who had a history of type two diabetes mellitus, chronic obstructive pulmonary disease, convulsions, and anxiety disorder, was dependent on staff for bathing and had moderate cognitive impairment. The resident's medical records indicated a need for regular podiatry follow-ups, but there were multiple missed appointments. The resident was seen by a podiatrist in October 2023, but subsequent appointments in January and March 2024 were either refused by the resident or canceled by the podiatrist. By June 2024, the resident had not been seen by a podiatrist, resulting in overgrown, curling, thick, and yellow toenails with dry and peeling surrounding skin. Interviews with the resident and staff confirmed the resident's desire for toenail care and the facility's failure to ensure timely podiatry services. The Assistant Director of Nursing verified the condition of the resident's toenails, acknowledging the risk for skin impairment. The Social Services Designee admitted to difficulties in rescheduling appointments and failing to follow up on the resident's podiatry care. The facility's policy required social services to ensure follow-up for ancillary services, which was not adhered to in this case.
Significant Medication Error Due to Incorrect Warfarin Dosage
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically affecting one resident. The resident, who had diagnoses including acute embolism and thrombosis of deep veins of the lower extremity and atherosclerotic heart disease, was admitted with severely impaired cognition. A physician's order was given to adjust the dosage of Warfarin, a blood thinner, to six milligrams on Mondays and Thursdays, while maintaining a five-milligram dose on other days. However, the Medication Administration Record (MAR) showed that the resident was administered both the five mg and six mg doses on eight separate days, contrary to the physician's instructions. The error was confirmed by the Director of Nursing, who acknowledged that the resident received incorrect dosages on multiple occasions. The facility's policy on medication administration requires staff to verify the correct medication, dose, route, rate, time, and resident each time a medication is administered. Despite this policy, the orders were entered incorrectly into the MAR, leading to the repeated administration of both doses. This oversight was documented in a progress note, which highlighted the presence of double orders for different doses of Warfarin, leading to the medication error.
Failure to Deliver Mail on Weekends
Penalty
Summary
The facility failed to ensure that residents received their mail on weekends, which had the potential to affect all 63 residents residing in the facility. During the annual survey, interviews with several residents revealed that mail was only delivered from Monday to Friday, and not on Saturdays. The Business Office Manager indicated that residents were supposed to receive mail on Saturdays, except for insurance-related mail, and that the activities department was responsible for distributing the mail. However, the Activities Director confirmed that mail was not handed out on Saturdays. A review of the resident rights handbook showed that residents had the right to send and receive mail, including receiving letters, packages, and other materials delivered to the facility, with privacy and access to necessary materials at their own expense.
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 254 citations issued within 25 miles in the last 12 months — including the 2 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) |
|---|---|---|---|---|
| Ohio Living Cape May | 0.9 mi | ★★★★★ | 10 | 0 |
| Autumn Years Nursing Center | 11.9 mi | — | 0 | 0 |
| Continental Manor Nurs And Rehabilitation Center | 12.4 mi | ★★★★★ | 3 | 0 |
| Laurels Of Blanchester, The | 13.1 mi | ★★★★★ | 0 | 0 |
| Jamestown Place Health And Rehab | 14.2 mi | ★★★★★ | 28 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Wilmington Nursing & Rehab.
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 October 2026) and official state health department websites.