Wilmington Nursing & Rehab

In the surveyor’s words

From the most serious findings on record at Wilmington Nursing & Rehab, in the surveyor’s own words.

• Actual harm, isolatedF684Mar 1, 2021

  Based on staff and physician interviews and review of the medical record, the facility failed to follow the hospital discharge medication list as well as transcribe verbal physician orders [REDACTED]. Actual harm occurred to Resident #38 when the facility failed to transcribe orders for blood glucose testing and subsequently the resident was found unresponsive with gurgling respirations, her skin tone was red, and she was in respiratory distress and had to be hospitalized for [REDACTED]. This affected one (#38) of three residents who were reviewed for quality of care. This had the potential to affect nine residents who had physician orders [REDACTED]. […]

• No harm, potential for more than minimal, widespreadF812Jun 11, 2026

  Based on observation, interview, and policy review, the facility failed to ensure food was distrubuted under sanitary conditions. This had the potential to affect all residents. The facility census was 63.Findings include:Observation on 06/09/2026 at 7:33 A.M. to 7:43 A.M. revealed [NAME] #230 preparing bacon for residents' meal trays. [NAME] #230 was grabbing the bacon using gloved hands and no tongs. [NAME] #230 also grabbed paper slips, trays, plates, and plastic wrappers with doughnuts while she continued grabbing the bacon with the same gloved hands. Interview at the time of the observation [NAME] #230 confirmed not using tongs to prepare the bacon. [NAME] #230 stated the gloves should have been changed after touching other items and surfaces. […]

• No harm, potential for more than minimal, widespreadF812Nov 8, 2023

  Based on observations, staff interview, and review of the facility policy the facility failed to store, prepare, distribute, and serve food under sanitary conditions. This had the potential to affect all 65 residents residing in the facility. Findings include: 1. Observation of the kitchen on 11/07/23 from 9:00 A.M. to 9:41 A.M. with Dietary Manager #100 revealed the following concerns: Observation of the four tray line warmers revealed the water under each bin the water was milk- like in color withfloating white particles. One of the bins had dried food on the sides of the bin. Observation of the shelves directly underneath the serving area revealed there food particles, a dirty scoop, a bottle of syrup, crumbled aluminum file and a plastic bin containing non-kitchen items. […]

• No harm, potential for more than minimal, widespreadF880Mar 15, 2022

  Based on observations, staff interview, policy review, review of information from the Centers for Disease Control and Prevention (CDC) and review of information from the Centers for Medicare and Medicaid Services (CMS), the facility failed to properly don (put on) personal protective equipment (PPE) and/or wash their hands to potentially prevent the spread of Coronavirus Disease 2019 (COVID-2019). This had the potential to affect all 62 residents residing in the facility. The facility census was 62. Finding include: 1. Observation on 03/08/22 at 2:44 P.M. of the facilities laundry room revealed housekeeper manager (HM) #114 and housekeeper (HK) #116 folding laundry with no mask or eye protection. Interview with HM #114 on 03/08/22 at 2:44 P.M. […]

• No harm, potential for more than minimal, patternF759Jun 11, 2026

  Based on observation, record review, interview, and facility policy, the facility failed to ensure medications were administered with a medication error rate less then 5%. This affected three (#28, #41, and #62) residents observed during medication administration. A total of 29 medication opportunities with three errors were observed for total error rate of 10%. The facility census was 63. Findings include: 1.Review of the medical records for Resident #28 revealed an admission date of 01/03/25. Diagnoses included dementia, peripheral vascular disease, and Alzheimer's disease. Review of physician orders dated 02/18/26 revealed Resident #28 had an order memantine 5 milligrams (mg) two tablets twice a day. Observation on 06/10/26 from 7:20 A.M. through 7:26 A.M. […]