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REGENCY HEALTHCARE & REHAB CENTER

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REGENCY HEALTHCARE & REHAB CENTER VS
All other Nursing Homes USA
General
City WILMINGTON   vs 0.2% Nursing Homes USA have WILMINGTON
State attribute explanation DE   vs 0.3% Nursing Homes USA have DE
Street 801 N. BROOM STREET  
Zip Code 19806  
Phone 3026523861  
Overall Star Rating
(1.11 lower than average)
vs
3.11

Health Inspections Star Rating
(1.83 lower than average)
vs
2.83

Nurse Staffing Star Rating
(0.83 higher than average)
vs
3.17

Quality Measures Star Rating
(0.69 higher than average)
vs
3.31

RN Only Star Rating
(0.83 higher than average)
vs
3.17

Number of Certified Beds
100  (8.94 lower than average)
vs
108.94

Total Number of Residents
93  (1.75 higher than average)
vs
91.25

Percent of Occupied Beds
93 % (9.35 % higher than average)
vs
83.65 %

Health Survey Date 5/2/2011  
Fire Survey Date 5/2/2011  
Sprinkler Status Fully Sprinklered  vs 90.2% Nursing Homes USA have Fully Sprinklered
Program Participation Medicare And Medicaid  vs 91.5% Nursing Homes USA have Medicare and Medicaid
Type of Ownership For Profit - Individual  vs 3.5% Nursing Homes USA have For profit - Individual
Located Within a Hospital? No  vs 93.6% Nursing Homes USA don't have Located Within a Hospital?
Multi Nursing Home Ownership? No  vs 45.1% Nursing Homes USA don't have Multi Nursing Home Ownership?
Resident and Family Councils Both  vs 29.8% Nursing Homes USA have Both
Continuing Care Retirement Community? No  vs 90.9% Nursing Homes USA don't have Continuing Care Retirement Community?
Quality Indicator Survey? Yes  vs 31.3% Nursing Homes USA have Quality Indicator Survey?
Special Focus Facility? No  vs 99% Nursing Homes USA don't have Special Focus Facility?
Civil Money Penalty Count
(57.16 lower than average)
vs
58.16

Total Enforcement Actions Count
(55.31 lower than average)
vs
56.31

# of deficiencies 20  
Staff Information
Number of Residents
93  (1.62 higher than average)
vs
91.38

Number of RN Hours Per Resident Per Day
0.73  (0.04 lower than average)
vs
0.77

Number of LPN/LVN Hours Per Resident Per Day
0.84  (equals average)
vs
0.84

Total Number of Licensed Staff Hours Per Resident Per Day
1.56  (0.03 lower than average)
vs
1.59

Number of CNA Hours Per Resident Per Day
0.05  (5.44 lower than average)
vs
5.49

Number Therapy Hours Per Resident Per Day
0.05  (0.05 lower than average)
vs
0.10

Environmental Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading.
survey Date: 04/20/2011
date Of Correction: 07/12/2011 

Deficiency #2 Scope: Few
level Of Harm: 3
deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.
survey Date: 04/20/2011
date Of Correction: 07/20/2011 

Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.
survey Date: 01/28/2010
date Of Correction: 03/12/2010 

Mistreatment Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: 1) Hire Only People With No Legal History Of Abusing, Neglecting Or Mistreating Residents; Or 2) Report And Investigate Any Acts Or Reports Of Abuse, Neglect Or Mistreatment Of Residents.
survey Date: 10/29/2010
date Of Correction: 12/16/2010 

Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: 1) Hire Only People With No Legal History Of Abusing, Neglecting Or Mistreating Residents; Or 2) Report And Investigate Any Acts Or Reports Of Abuse, Neglect Or Mistreatment Of Residents.
survey Date: 01/28/2010
date Of Correction: 03/12/2010 

Resident Rights Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Immediately Tell The Resident, The Resident's Doctor And A Family Member Of The Resident Of Situations (injury/decline/room, Etc.) That Affect The Resident.
survey Date: 02/15/2012
date Of Correction: 05/10/2012 

Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Immediately Tell The Resident, The Resident's Doctor And A Family Member Of The Resident Of Situations (injury/decline/room, Etc.) That Affect The Resident.
survey Date: 10/29/2010
date Of Correction: 01/28/2011 

Quality Care Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .
survey Date: 04/20/2011
date Of Correction: 07/12/2011 

Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .
survey Date: 10/29/2010
date Of Correction: 02/10/2011 

Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.
survey Date: 10/29/2010
date Of Correction: 12/16/2010 

Deficiency #4 Scope: Some
level Of Harm: 2
deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .
survey Date: 01/28/2010
date Of Correction: 03/12/2010 

Deficiency #5 Scope: Few
level Of Harm: 2
deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.
survey Date: 01/28/2010
date Of Correction: 03/12/2010 

Deficiency #6 Scope: Few
level Of Harm: 2
deficiency: Provide Medically-related Social Services To Help Each Resident Achieve The Highest Possible Quality Of Life.
survey Date: 01/28/2010
date Of Correction: 03/12/2010 

Resident Assessment Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Allow The Resident The Right To Participate In The Planning Or Revision Of The Resident's Care Plan.
survey Date: 02/15/2012
date Of Correction: 05/10/2012 

Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Develop A Complete Care Plan That Meets All Of A Resident's Needs, With Timetables And Actions That Can Be Measured.
survey Date: 02/15/2012
date Of Correction: 05/10/2012 

Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: Allow The Resident The Right To Participate In The Planning Or Revision Of The Resident's Care Plan.
survey Date: 10/29/2010
date Of Correction: 01/28/2011 

Deficiency #4 Scope: Few
level Of Harm: 2
deficiency: Allow The Resident The Right To Participate In The Planning Or Revision Of The Resident's Care Plan.
survey Date: 01/28/2010
date Of Correction: 03/12/2010 

Administration Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.
survey Date: 10/29/2010
date Of Correction: 01/28/2011 

Pharmacy Service Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 3
deficiency: Make Sure That Residents Are Safe From Serious Medication Errors.
survey Date: 10/29/2010
date Of Correction: 12/16/2010 

Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Safely Provide Drugs And Other Similar Products Available, Which Are Needed Every Day And In Emergencies, By A Licensed Pharmacist.
survey Date: 01/28/2010
date Of Correction: 03/12/2010 

Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication 17.3:1 % 
Percent of long-stay residents whose need for help with daily activities has increased
75.2 % (42.25 % higher than average)
vs
32.95 %

Percent of long-stay residents who self-report moderate to severe pain
10 % (6.66 % lower than average)
vs
16.66 %

Percent of long-stay high-risk residents with pressure ulcers 8.9 / 9.9 % 
Percent of long-stay residents who lose too much weight
6.1 % (5.73 % lower than average)
vs
11.83 %

Percent of long-stay residents who have had a catheter inserted and left in their bladder
5.4 % (10.23 % lower than average)
vs
15.63 %

Percent of long-stay residents with a urinary tract infection
7.3 % (6.16 % lower than average)
vs
13.46 %

Percent of long-stay residents who have depressive symptoms
2.4 % (25.98 % lower than average)
vs
28.38 %

Percent of long-stay residents who were physically restrained
75.2 % (31.52 % higher than average)
vs
43.68 %

Percent of short-stay residents who self-report moderate to severe pain 13.9 / 15.3 % 
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
55.2 % (29.44 % lower than average)
vs
84.64 %

Percent of short-stay residents with Pressure ulcers that are new or worsened
53.6 % (30.34 % lower than average)
vs
83.94 %

Percent of short-stay residents who newly received an antipsychotic medication
75.2  (29.3 higher than average)
vs
45.90

Percent of long-stay residents experiencing one or more falls with major injury
2.4 % (13.12 % lower than average)
vs
15.52 %

Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication
17.6 % (7.79 % lower than average)
vs
25.39 %

Percent of long-stay residents whose need for help with daily activities has increased
0.7 % (23 % lower than average)
vs
23.70 %

Percent of long-stay residents who self-report moderate to severe pain
14.3 % (0.2 % higher than average)
vs
14.10 %

Percent of long-stay high-risk residents with pressure ulcers
6.2 % (3.02 % lower than average)
vs
9.22 %

Percent of long-stay residents who lose too much weight
6.7 % (1.8 % lower than average)
vs
8.50 %

Percent of long-stay low-risk residents who lose control of their bowels or bladder
30.3 % (13.08 % lower than average)
vs
43.38 %

Percent of long-stay residents who have had a catheter inserted and left in their bladder
5.5 % (5.15 % lower than average)
vs
10.65 %

Percent of long-stay residents with a urinary tract infection
7.1 % (2.48 % lower than average)
vs
9.58 %

Percent of long-stay residents who have depressive symptoms
1.6 % (18.26 % lower than average)
vs
19.86 %

Percent of long-stay residents who were physically restrained
75.2 % (36.67 % higher than average)
vs
38.53 %

Percent of long-stay residents experiencing one or more falls with major injury
2.7 % (8.03 % lower than average)
vs
10.73 %

Percent of short-stay residents who self-report moderate to severe pain
19.2 % (5.56 % lower than average)
vs
24.76 %

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
61.7 % (19.74 % lower than average)
vs
81.44 %

Percent of short-stay residents with Pressure ulcers that are new or worsened
44.3 % (30.45 % lower than average)
vs
74.75 %

Percent of short-stay residents who newly received an antipsychotic medication
15.7 % (1.64 % lower than average)
vs
17.34 %



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