Public Record
Encore at Windsor Hills
From CMS
Facility profile
- CMS overall rating
- 5 / 5
- Certified beds
- 46
- Avg. residents per day
- 43
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 28
- Inspections on file
- 4
- Last inspection
- 2025-03-21
*CMS
*CMS
*CMS
Citations
28 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0697Generalpotential for harm
Provide safe, appropriate pain management for a resident who requires such services.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0911Generalpotential for harm
Meet requirements for the installation and maintenance of electrical systems.
- 0712Generalpotential for harm
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0644Generalpotential for harm
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- 0804Generalpotential for harm
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- 0131Generalpotential for harm
Meet requirements for sections of health care facilities separated by fire resistive construction.
- 0225Generalpotential for harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- 0232Generalpotential for harm
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0372Generalpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0511Generalpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0623Generalpotential for harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- 0761Generalpotential for harm
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0689Seriousactual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0697Generalpotential for harm
Provide safe, appropriate pain management for a resident who requires such services.
- 0732Generalno actual harm
Post nurse staffing information every day.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0814Generalpotential for harm
Dispose of garbage and refuse properly.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0888Generalpotential for harm
Ensure staff are vaccinated for COVID-19
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspection history
Every health inspection on record
Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.
- View inspection reportInspection2 deficiencies
- View inspection reportInspection15 deficiencies
- View inspection reportInspection15 deficiencies
- View inspection reportInspection11 deficiencies
FAQ
Questions and answers
- What is Encore at Windsor Hills?
- Encore at Windsor Hills is a Medicare- and Medicaid-certified nursing home in Wilmington, DE, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 085060.
- What is the CMS rating for Encore at Windsor Hills?
- Encore at Windsor Hills has a CMS overall rating of 5 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Encore at Windsor Hills have?
- Encore at Windsor Hills is certified for 46 beds. It serves an average of 43 residents per day.
- How many citations does Encore at Windsor Hills have?
- Encore at Windsor Hills has 28 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Encore at Windsor Hills last inspected?
- Encore at Windsor Hills was last inspected on March 21, 2025. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
/nursing-home/085060-encore-at-windsor-hills