Deficiency Records for Wilmington Nursing and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Wilmington Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-08-10 | 2024-01-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-10 | 2023-12-06 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-08-10 | 2023-12-06 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-08-10 | 2023-12-06 | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2023-08-10 | 2023-12-06 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-08-10 | 2023-12-06 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-08-10 | 2023-12-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-10 | 2023-12-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-10 | 2023-12-06 | N |
| 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. | Health | 2023-08-10 | 2023-12-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-10 | 2023-12-06 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-08-10 | 2023-12-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-10 | 2023-12-06 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-08-10 | 2023-12-06 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-08-10 | 2023-12-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-10 | 2023-12-06 | N |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2023-08-10 | 2023-12-06 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-08-10 | 2023-12-06 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-08-10 | 2023-12-06 | N |
| Provide training in compliance and ethics. | Health | 2023-08-10 | 2023-12-06 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-10 | 2023-09-25 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-08-10 | 2023-09-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-10 | 2023-09-25 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-08-10 | 2023-09-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-10 | 2023-09-25 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-08-10 | 2023-09-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-10 | 2023-09-25 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-08-10 | 2023-09-25 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-08-10 | 2023-09-25 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-08-10 | 2023-09-25 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-08-10 | 2023-09-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-10 | 2023-09-25 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-08-10 | 2023-09-25 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-08-10 | 2023-09-25 | N |
| Keep all essential equipment working safely. | Health | 2023-08-10 | 2023-09-25 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2023-08-10 | 2023-09-25 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-08-10 | 2023-09-25 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-08-10 | 2023-09-25 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2023-08-10 | 2023-09-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-09 | 2023-09-11 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-08-09 | 2023-09-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-09 | 2023-09-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-09 | 2023-09-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-09 | 2023-09-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-08-09 | 2023-09-11 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-04-27 | 2021-05-13 | Y |
| Report COVID19 data to residents and families. | Health | 2021-04-27 | 2021-05-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-11-25 | 2020-01-21 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-11-25 | 2020-01-21 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-11-25 | 2020-01-21 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-25 | 2020-01-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-25 | 2020-01-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-10-02 | 2018-11-19 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-10-02 | 2018-11-19 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-10-02 | 2018-11-19 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-10-02 | 2018-11-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-02 | 2018-11-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-10-02 | 2018-11-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-10-02 | 2018-11-19 | N |
| Provide activities to meet all resident's needs. | Health | 2018-10-02 | 2018-11-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-10-02 | 2018-11-19 | N |
| 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. | Health | 2018-10-02 | 2018-11-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-02 | 2018-11-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-10-02 | 2018-11-19 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-10-02 | 2018-11-19 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-10-02 | 2018-11-19 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-10-02 | 2018-11-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-02 | 2018-11-19 | N |
| Dispose of garbage and refuse properly. | Health | 2018-10-02 | 2018-11-19 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2018-10-02 | 2018-11-19 | N |
