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Regency Healthcare & Rehab Center

801 N. Broom Street, Wilmington, DE 19806 · For profit - Limited Liability company · 100 certified beds · (302) 654-8400 Medicare & Medicaid certified

Call the home — (302) 654-8400 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0602) — most recent Feb 20251 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$77,867 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Feb 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (19) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $77,867 in federal fines (most recent 2024-12-31)
  • its facility-reported quality-measure rating is low (2/5)
  • nursing-staff turnover (64%) runs well above the national median (45%)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
700 N Clayton St · (302) 575-8040 · Call to confirm hours
Pharmacy
1835 W 4th St · (302) 425-4100 · Call to confirm hours
Grocery
1322 W 4th St · (302) 654-5992 · Call to confirm hours
Park
Tiltlandia<0.1 mi
1314 W 7th St · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 1 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-09 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased11.9%12.7%15.4%better
Long-stay residents who lose too much weight4.4%5.4%5.4%better
Long-stay residents with a catheter left in their bladder0.8%0.4%0.9%typical
Long-stay residents with a urinary tract infection1.2%2.1%2.0%better
Long-stay residents with depressive symptoms0.0%10.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.0%3.2%3.3%better
Long-stay residents whose ability to walk worsened14.5%13.6%16.1%typical
Long-stay residents on antianxiety or hypnotic medication14.4%21.8%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%97.4%95.3%typical
Long-stay residents with pressure ulcers5.8%3.5%4.7%worse
Long-stay residents with worsening bladder/bowel control26.4%20.2%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table9.3%10.7%17.1%better
Short-stay residents who newly got an antipsychotic medication1.3%1.0%1.4%typical
Short-stay residents given the seasonal flu vaccine94.8%83.1%79.4%better
Short-stay residents rehospitalized after admission24.5%23.3%22.6%typical
Short-stay residents with an outpatient ER visit17.1%11.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.601.811.67worse
Long-stay outpatient ER visits per 1,000 resident days5.241.401.80worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

50.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 32 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.3%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
36.7%U.S. median 56.6%
Met the expected recovery
0.29U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.18hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 36.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 30 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.29 therapist hours per resident per day in 2026Q1 — more than 44% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF50.3%CMS range 34.9–65.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 7.2–14.710.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge36.7%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge40.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge43.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified89.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened5.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.8%CMS range 4.5–16.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.991.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.65
RN hours/ resident / day
1.00
LPN hours/ resident / day
2.09
Aide hours/ resident / day
3.74
Total nurse hours/ resident / day
0.40
RN hoursweekends
63.8%
Total nursing turnover
52.9%
RN turnover

How full it usually is: this home is certified for 100 beds and averages 91.7 residents a day — about 92% occupied, or roughly 8 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.74 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.65 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.09 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.44 hrs/resident/day on weekends vs 3.87 on weekdays — 11% thinner on weekends. RN hours go from 0.76 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 64% is well above the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

2
deficiencies at the latest standard inspection (2025-07-01)
7
at the previous standard inspection (2025-02-04)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

19 citations, most serious first. The 12 most serious are shown; the remaining 7 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2023-12-15 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review and review of other facility documentation it was determined that for one (R37) out of twelve residents reviewed for abuse, the facility failed to prevent abuse. For R37 sexual abuse by a staff CNA (Certified Nursing Assistant). An immediate jeopardy (IJ) was identified starting on 6/5/23. Due to the facility's corrective measures following the incident, this is being cited as immediate jeopardy, past non-compliance with an abatement date of 6/10/23. R37 had sustained psychosocial harm as R37 was still affected by the abuse. Findings include: A facility policy and procedure titled Identifying Types of Abuse documented . 1. As part of the abuse prevention strategy, volunteers, employees, and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents . 2. Abuse of any kind against residents is strictly prohibited . 3. Abuse towards a resident can occur as staff to resident abuse . 4. Sexual abuse is non-consensual conduct of any type with a resident . 5. Abuse may result in…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Actual harm · G2024-12-31 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, it was determined that for one (R2) out of three residents reviewed for accidents, the facility failed to provide a safe environment by having two staff members present to assist with turning when R2 received a shower on 10/25/24. R2 sustained harm due to the traumatic removal of the nephrostomy tube during care and needed to be transported to the hospital for emergency treatment. On 10/26/24, R2 was again sent to the emergency room for evaluation of the injuries to his face, torso and lower extremeties. Based on review of the facility's evidence to correct the non-compliance and the facility's substantial compliance at the time of the current survey, this deficiency was determined to be past non-compliance as of 10/29/24. Findings include: R2's clinical records revealed: 2/26/16 - R2 was admitted to the facility with diagnoses including traumatic brain injury, tracheostomy, enteral tube feeding and neuromuscular dysfunction of the bladder (which required the use of a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2025-07-01 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that for one (R11) out of two residents reviewed for ADLs (Activities of Daily Living) and one (R27) out of six residents reviewed for abuse, the facility failed to follow the plan of care. For R11, a soiled and wet dressing was not changed per the physician's order. For R27, the facility failed to ensure re-admission orders on 6/28/25 were reviewed by on call provider and transcribed accurately. Findings include: 1. Review of R11's clinical record revealed: 6/19/25 - R11 was re-admitted to the facility and required assistance with personal care. 3/26/25 - A review of R11's quarterly MDS assessment revealed that R11 had intact cognition. 6/20/25 - R11 had a physician's order to cleanse the right wrist skin tear with NSS pat dry apply Xeroform (gauze dressing for wounds with drainage) and CDD daily and PRN (when necessary) every evening shift. 6/26/25 9:00 AM - During an observation, R11 was seen from the shower room being wheeled to the nurses' station by…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-01 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, it was determined that for one (R73) out of two residents reviewed for dental, the facility failed to provide the opportunity for follow up dental services. Findings include: Review of R73's clinical record revealed: 2/11/23 - R73 was admitted to the facility with diagnoses including dementia. 10/13/24 - A review of P1's (Dental) Report of Consultation documented, . Pt [R73] refused dental exam and treatment today .Recommendation: Pt would need pre-sedation prior to further treatment or dental exam. A handwritten note was also noted on the same consultation report documenting, . check oral cavity for follow up need .resident need a follow up, nursing to make apt (appointment). 11/19/24 - R73 had a physician's order to consult dental for evaluation and treatment as indicated. 11/25/24 - R73's annual MDS assessment revealed that his cognition was moderately impaired. 6/24/25 - During a telephone interview, FM1 (Family Member) stated, Dad [R73] never had any dental consults since last year. I was not notified. Last time I saw him, his teeth looked…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-02-04 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, it was determined that for three (R23, R89 and R43) residents reviewed for care plans the facility failed to develop and implement person-centered care plans, that included measurable objectives and timeframes, to meet each residents' needs. Findings include: Cross refer to F641 and F676 1. R23's clinical record revealed: 11/8/24 - R23 was admitted to the facility. 11/9/24 7:41 AM - R23's admission evaluation documented: . 8. Preferred Language: SPANISH 9. Do you need or want an interpreter to communicate with a doctor or health care staff? YES . 11/14/24 - The admission MDS assessment, under Section A, incorrectly documented that R23's preferred language was English. From 11/8/24 through 1/7/25, R23 lacked a person-centered communication care plan as a Spanish-speaking resident. 1/8/25 - Two months after R23 was admitted to the facility, a care plan was initiated for communication problem related to language barrier with an approach that included, but was not limited to, obtaining translation services. 1/13/25 - R23 was discharged to home.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-04 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review and interview, it was determined that for one (R43) out of one sampled resident, the facility failed to ensure the physician's order to administer quetiapine fumarate (Seroquel) . Findings include: Cross refer F600 Review of R43's clinical record revealed: 7/24/24 - R43 was admitted to the facility with diagnoses including dementia. 7/25/24 - R43 was care planned for receiving antipsychotic medication (to help manage his aggressive behaviors) and is at risk for behaviors and side effects. 7/30/24 - R43 was care planned for behavior as evidenced by physical aggression and interventions included to administer meds as ordered. 11/7/24 - R43 had a physician's order for quetiapine fumarate (Seroquel) 50 mg give 1 tablet by mouth two times a day for bipolar disorder. 12/3/24 1:11 PM - A nurse progress noted documented, . quetiapine fumarate . med presently N/A (not available), reordered from pharmacy . 12/4/24 10:15 AM - A nurse progress note documented, . quetiapine fumarate . med not delivered from pharmacy despite being reordered. Spoke to pharmacy and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-02-04 · tag F0802 — failed to prepare enough nourishing food — pattern
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview it was determined that the facility failed to ensure that a qualified person in charge was present during all hours of operation. The presence of a certified food protection manager reduces the risk for a foodborne outbreak especially for vulnerable populations. CMS recognizes the U.S. Food and Drug Administration's (FDA) Food Code and the Centers for Disease Control and Prevention's (CDC) food safety guidance as national standards to procure, store, prepare, distribute, and serve food in long term care facilities in a safe and sanitary manner. 1/29/25 11:00 AM - Review of the kitchen staff work schedule provided by E23 (District Food Service Manager) revealed that only one staff person E22 (Food Service Manager) out of three (E22, E23 and E25) who possessed valid Food Protection Manager certificates from an Accredited Food Safety Program was scheduled to work from 12/1/24 through 12/28/24. E22 was scheduled to work seventeen days out of twenty-eight on the December 2024 kitchen staff schedule and eight days out of fourteen on the partial January…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-04 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review and review of other facility documents, it was determined that for two (R42 and R43) out of eight residents reviewed for abuse, the facility failed to ensure that R42 was free from resident - to - resident physical abuse by R43 and R43 was free from physical abuse by R42. Findings include: A review of the facility's abuse policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, indicated, . The resident abuse, neglect and exploitation prevention program .1. Protect residents from abuse . by anyone including , other residents; . Cross refer F600 Ex. 2., F684 and F690 1. A review of R43's clinical record revealed the following: 5/25/22 - R43 was initially admitted to the facility with diagnoses including dementia. 7/30/24 (revised 1/31/25) - R43's behavioral care plans included, physical aggression/abuse against others including, hitting resident on arm, throwing water on a resident and repeated episodes of aggression. R43's care plan approaches included, Administer medications as ordered, allow resident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-04 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, it was determined that for three (R23, R53 and R89) out of three residents reviewed for communication the facility failed to ensure eash residents' MDS assessments accurately reflected their status. Findings include: 1. Cross refer to F656 and F676 R23's clinical record revealed: 11/8/24 - R23 was admitted to the facility. 11/9/24 7:41 AM - R23's admission evaluation documented: . 8. Preferred Language: SPANISH 9. Do you need or want an interpreter to communicate with a doctor or health care staff? YES . 11/14/24 - The admission MDS assessment, under Section A, documented that R23's preferred language was English. 2/4/25 at 1:30 PM - During an interview, E14 (RNAC) reviewed the 11/14/24 admission MDS and confirmed the MDS should have indicated Spanish as the preferred language. 2. R53's clinical record revealed: 11/16/24 - R53 had an active physician's order for depakote an anticonvulsant medication every 12 hours. 11/25/24 - An acute progress note by E24 (NP) documented to continue with depakote. 11/28/24 - The quarterly MDS assessment, under…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-04 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, it was determined that for one (R69) out one resident reviewed for mood/behavior, the facility failed to coordinate with the PASRR program under Medicaid and refer the resident for an assessment. Findings include: 1. R69's clinical record revealed: 12/17/24 - A PASRR Level 1 Screen was completed by the hospital and documented that R69 had no mental health diagnosis known or suspected and no current mental health medications prescribed. 12/27/24 - R69 was admitted to the facility. 1/13/25 - A psychiatric evaluation documented, . past psychiatric history of depression and anxiety . review of psychotropic med (medication) regimen and management of mood/behaviors . Does endorse feelings of anxiousness intermittently . Available records prior to facility admit reviewed and appreciated. Reportedly w/ (with) lengthy psych history and diagnosis of anxiety as well as depression . noted h/o (history of) paranoia. Resident was previously treated in the past with Olanzapine [antipsychotic] . 1/13/25 - A physician's order prescribed mirtazapine medication…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-04 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, it was determined that for one (R23) out of three residents reviewed for communication, the facility failed to provide Spanish-speaking translation/interpretation services during nursing care for R23. Findings include: The facility's policy and procedure entitled Translation and/or Interpretation of Facility Services, revised November 2020, stated, This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility . 6. Competent oral translation of vital information that is not available in written translation . shall be provided in a timely manner . 10. It is understood that in order to provide meaningful access to services provided by this facility, translation and/or interpretation must be provided in a way that is culturally relevant and appropriate to the LEP individual . Cross refer to F641 and F656 11/8/24 - R23 was admitted to the facility. 11/9/24 at 7:41 AM - R23's admission evaluation documented: . 8. Preferred…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-04 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, it was determined that for one (R43) out of three residents reviewed for bowel and bladder, the facility failed to evaluate R43's decline in urinary continence and failed to maintain or restore continence after R43's multiple falls related to his need for toileting assistance. Findings include: Cross refer F600 and F684 A review of R43's clinical records revealed the following: 7/24/24 - R43 was admitted to the facility with diagnoses including but not limited to dementia. 7/25/24 - R43 was care planned for ADL (Activities of Daily Living) deficit related cognition with interventions including assisting R43 to attend activities of choice. In addition, R43 was set up for care and supervise/verbal dues (sic) to assure he follow thru. 7/25/24 - R43 was care planned for falls related to .poor safety awareness .with interventions including offering toileting before going to bed (8/14/24) and reminding R43 not to go to the bathroom without help (10/25/24). 7/31/24 -…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 7 citations
  • Potential for harm · E2024-12-31 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that for one (R5) out of three residents reviewed for pharmacy services, the facility failed to obtain and administer three ordered medications (lacosamide, clonazepam, perampanel) to R5 from 12/27/24 to 12/29/24, which resulted in multiple missed doses of each medication. Findings include: Cross refer F710 R5's clinical record revealed: 12/27/24/ 11:14 AM - C1 (hospital physician assistant) documented in R5's interagency discharge orders, . Discharge Diagnoses: fracture of right radius (arm) . seizure . Medication Orders Upon discharge: . lacosamide 200 mg - 1 tablet by mouth two times a day . perampanel (Fycomba) 6 mg - give 1 tablet by mouth at bedtime for seizure prevention . clonazepam 1 mg - take 1 tablet by mouth every 12 hours . 12/27/24 Friday - R5 was admitted to the facility with diagnoses, including but were not limited to, seizures and anxiety disorder. 12/27/24 - E10 (MD/ Medical Director) ordered in R5's EMR (electronic medical record), .…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-31 · tag F0710 — isolated
    Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, it was determined that for one (R5) out of three residents reviewed for Physician services, the facility failed to ensure the physician/provider completed the required Control Prescription [C2- a required form for any controlled (Drug Enforcement Administration's drug schedules II through V) medications that the pharmacy must have completed with the provider's signature and DEA number in order to release the medication to the facility)] form for three medication orders (lacosamide, clonazepam, perampanel) that were necessary for R5's immediate care. Findings include: The Drug Enforcement Administration (DEA)'s drug schedule classifies drugs into different groups based on their risk of abuse or harm. (www.dea.gov) Cross refer F755 Review of R5's clinical record revealed: 12/27/24 Friday 6:36 PM - R5 was admitted to the facility with diagnoses, including but were not limited to, seizures and anxiety. 12/27/24 - E10 (MD/Medical Director) ordered in R5's EMR, .clonazepam (anti-anxiety medication) 1 mg- give 1 tablet by mouth every 12 hours for anxiety .Fycomba…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-09 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, it was determined that the facility failed to report R1's allegation of sexual abuse to the Administrator or the State Agency within two hours when it became known on the weekend of 10/5/24. The facility reported the allegation on 10/8/24. Findings include: The facility's policy entitled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, last revised September 2022, stated, . 1. If resident abuse . is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law . 3. 'Immediately' is defined as: a. within two hours of an allegation involving abuse . Review of R1's clinical record revealed: 11/16/22 - R1 was admitted to the facility with diagnoses, including but was not limited to, stroke with left-sided weakness. 8/15/24 - R1's quarterly Minimum Data Set (MDS) assessment documented R1's Basic Inventory of Mental Status (BIMS) score of 14, which was reflective of normal cognitive function. 10/8/24 10:40 AM - During an interview, R1 stated that the encounter of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-17 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, it was determined that for one (R95) out of nine sampled residents reviewed for abuse, the facility failed to protect R95 from verbal abuse. Findings include: Review of R95's closed clinical record revealed: 11/23/22 - R95 was admitted to the facility. 5/25/23 - R95 had a care plan for physical and verbal aggression. Interventions included but not limited to listen to resident and try to calm. 8/24/23 - R95 had a care plan for verbal aggression to staff, yelling and threatening to have staff fired and interfering with care and disruptive behavior in the dining hall. Interventions included listen to resident and try to calm. 5/15/24 3:10 PM - A facility incident report submitted to the State agency documented that R95 was in the dining room awaiting dinner service. R95 got frustrated when he felt that E6 was ignoring him and yelled (fuck). E6 then cursed R95 and yelled at him. 5/15/24 - A written statement by E5 (RN) documented, At approximately 1715 (5:15 PM), I heard a screaming from the dining room. I saw [E6] at the entrance of the dining…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-17 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, record review and interview, it was determined that for one (R40) out of one resident reviewed for hearing and visioin the facility failed to ensure the MDS was accurate for one (R40). Findings include: A review of R40's clinical record revealed: 5/2/23 - Resident was admitted to the facility. 5/2/23 - An inventory list included hearing aid and charger on admission. 5/7/24 - An annual MDS documented Hearing aid or other hearing appliance used. The response was recorded as No. 5/15/24 - A review of R40's care plan states that R40 is at risk for impaired communication. [R40] is very hard of hearing. 7/16/24 11:33 AM - During an interview with E8 (RNAC) it was confirmed that the MDS for hearing was wrong. Findings were reviewed with E1 (NHA) and E2 (DON) during the Exit Conference on 7/17/24 at approximately 2:00 PM.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-12-15 · tag F0688 — failed to keep residents mobile / prevent decline — pattern
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview it was determined for one (R37) out of one resident reviewed for range of motion (ROM) the facility failed to ensure the resident received the ordered foot brace to prevent a decline in range of motion. Findings include: The facility policy on resident mobility and range of motion last updated July 2017 indicated, Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility . Review of R37's clinical record revealed: 3/18/22 - R37 was admitted to the facility with multiple diagnoses including weakness and paralysis affecting the left side. 10/20/23 - A therapy order was written by E8(RD) for R37 to wear left foot brace at night on after evening care, off after morning care for foot drop as tolerated. 10/20/23 - A care plan for alteration in mobility requiring restorative nursing program related to decreased strength upper and lower extremities was updated to include the intervention for R37 to wear left foot brace at night on after evening care off after morning care. October 20 - 31…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-15 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview it was determined that for two (R438 & R47) out of three residents reviewed for pain, the facility failed to ensure PRN narcotic pain medications were not inappropriately diverted to an agency nurse on 8/23/23. Due to the facility's corrective measures following the incident, this is being cited as past non-compliance. Findings include: 1. Review of R438's clinical record revealed: 7/25/23 - R438 was admitted to the facility with diagnoses including but not limited to multiple sclerosis and diabetes. 7/26/23 - R438 was ordered Oxycodone (narcotic pain relief medicine) 5 mg (milligrams) by mouth every 6 hours PRN (as needed order) for pain level 5-10. 8/23/23 1:28 PM - E44 (LPN) documented administering oxycodone 5mg by mouth to R438. Review of R438's medication administration record (MAR) by this surveyor revealed R438's pain scale was assessed every shift for the month of August 2023 and 100 percent of the time the pain level was documented as 0. R438 had only 4 doses of oxycodone in the month of August 2023; two of those four doses were…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$77,867 in federal fines across 2 penalties.

  • $12,035 — penalty dated 2024-12-31
  • $65,832 — penalty dated 2023-12-15

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to NATIONWIDE HEALTHCARE SERVICES — 7 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 52.6+1.4 vs chain
Health inspection 4 of 52.6+1.4 vs chain
Staffing 4 of 52.9+1.1 vs chain
Quality measures 2 of 53.1-1.1 vs chain
The other 6 homes this chain runs (chain average 2.6★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
GELLEY, LEAHIndividual5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/01/2007
GELLEY, MEIRIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEENO PERCENTAGE PROVIDEDsince 05/01/2007

CMS files one row per role, so the 3 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$11.3M
Net patient revenuemost recent cost report
-18.0%
Operating marginrevenue minus expenses
$1.7M
Related-party expense13% of expenses
Who pays — share of resident-days
Medicaid 82%Medicare 8%Other / private 10%

About 82% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$407per resident / day
operating cost
$12,373per month
≈ monthly operating cost
$345per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in DE

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Delaware Medicaid page.

Typical monthly cost in Delaware
$14,494/mo
Nursing home (semi-private)
$15,132/mo
Nursing home (private)
$7,600/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 085012. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-01, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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