Excelcare at Wilmington LLC

In the surveyor’s words

From the most serious findings on record at Excelcare at Wilmington LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Mar 1, 2024

  Based on record review, interviews, and facility policy review, the facility failed to ensure residents were free from physical abuse from: 1. one resident (Resident (R) 95) who demonstrated repeated acts of physical violence towards multiple other residents to include residents R24 and R109; and 2. R128's wandering behavior resulted in a resident-to-resident abuse between R128 and R6. The facility's Administrator was informed on [DATE] at 3:40 PM that Immediate Jeopardy (IJ) existed at F600-K Freedom from Abuse and Neglect when the facility failed to implement effective interventions to ensure residents were free from abuse from R95. The facility provided an acceptable removal plan for the Immediate Jeopardy on [DATE] at 12:21 AM. […]

• No harm, potential for more than minimal, patternF880Mar 1, 2024

  Based on observations, interview, record reviews, and facility policy review, the facility failed to ensure four out of four isolation carts were fully stocked with the supplies needed to promote infection control, Resident (R) 30 did not consume a pill dropped on the ground, and staff utilized proper hand hygiene after wiping R116's nose of 41 sampled residents. Findings include: 1. During an observation on 02/26/24 at 10:30 AM, room [ROOM NUMBER] had signage on the door showing that the room was an isolation room and isolation carts were outside the door. The signage included contact precautions and droplet precautions and indicated a face shield, or goggles were to be donned (put on) when entering the room. […]

• No harm, potential for more than minimal, patternF689Mar 10, 2023

  Based on observation and interview, it was determined that the facility failed to maintain safe water temperatures for the sinks in resident bathrooms and a shower room on one out of three resident units. Additionally, one out of four of the facility's boilers was set to 141 degree's. Findings include: 3/3/23 - Following initial pool observations of hot to touch water temperatures, the following water temperatures were obtained by E26 (Maintenance Director): 10:13 AM - room [ROOM NUMBER] bathroom sink water temperature was 122 F. 10:15 AM - Unit 300 shower room sink water temperature 131.5 F. 10:29 AM - room [ROOM NUMBER] bathroom sink water temperature 137.8 F. 10:31 AM - room [ROOM NUMBER] bathroom sink water temperature 125.0 F. […]

• No harm, potential for more than minimal, isolatedF646Nov 12, 2025

  Based on record review and interview, it was determined that for one (R1) out of nine residents reviewed for resident rights, the facility failed to initiate a PASARR (Pre-admission Screening and Resident Review) review when R1 was started on a new anti-psychotic medication. Findings include:7/5/23 - R1's PASARR determined that R1 required a PASARR level II without specialized services. 7/7/23 - R1 admitted to the facility with a diagnoses, including but was not limited to, bipolar disorder.1/19/24 - Delusional disorder was added to R1's diagnoses list as evidenced by dates on R1's facility facesheet.This diagnosis was not documented on R1's 7/5/23 PASARR evaluation.3/6/25 - C1 (psychiatrist) documented in R1's progress notes, .Patient on Zyprexa (olanzapine) for off-label use was… […]

• No harm, potential for more than minimal, isolatedF842Nov 12, 2025

  Based on record review and Interview, it was determined that for two (R1 and R2) out of nine residents reviewed for resident rights, the facility failed to ensure the medical records were in accordance with professional standards by being accurate.1. Review of R1's clinical record revealed:7/7/23 - R1 was admitted to the facility with diagnoses, including bit was not limited to, bipolar disorder.8/29/25 11:45 AM - From reading the facility's investigation report, there was a heated interaction between R1 and R4 during a room change. 8/29/25 2:53 PM - E8 (LPN) documented in R1's progress notes, Incident note: Officer [name] responded to the facility and interviewed [R1]. […]