ENCORE AT WINDSOR HILLS
Open-data reference.
ENCORE AT WINDSOR HILLS is a for profit - corporation facility in WILMINGTON, DE with 46 certified beds and a 5-star overall CMS rating. The facility has 19 deficiency records on file. Total penalties: $20K.
1212 FOULK ROAD, WILMINGTON, DE 19803
Phone: 3024784296
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 085060
- Ownership
- For profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 46
- Residents
- 44
- In Hospital
- No
- County
- New Castle
- Last Inspection
- Feb 26, 2024
Staffing Data
- RN Hours
- 1.25 (nat'l avg: 0.68)
- LPN Hours
- 0.61
- CNA Hours
- 2.59
- Total Nursing Hours
- 4.45 (nat'l avg: 3.89)
- PT Hours
- 0.09
- Nursing Turnover
- 12.5%
- RN Turnover
- 16.7%
What the CMS Record Reveals About ENCORE AT WINDSOR HILLS
ENCORE AT WINDSOR HILLS operates 46 certified beds in WILMINGTON, DE with approximately 44 residents currently in care, and carries a CMS overall rating of 5 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (4★), staffing levels (5★), and quality measures (5★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 19 deficiency records from recent surveys, of which 1 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 2 penalties totaling $20K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 4.45 total nursing hours per resident day (national average 3.89), with RN coverage at 1.25 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, ENCORE AT WINDSOR HILLS falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 12.5%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (19 most recent)
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 1, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Apr 1, 2024
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Category: Nursing and Physician Services Deficiencies
Corrected: Apr 1, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 5, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 1, 2024
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category: Nutrition and Dietary Deficiencies
Corrected: Apr 1, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Apr 1, 2024
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category: Resident Rights Deficiencies
Corrected: Apr 1, 2024
Ensure staff are vaccinated for COVID-19
Category: Infection Control Deficiencies
Corrected: Jul 5, 2022
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jul 5, 2022
Dispose of garbage and refuse properly.
Category: Nutrition and Dietary Deficiencies
Corrected: Jul 5, 2022
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Jul 5, 2022
Post nurse staffing information every day.
Category: Nursing and Physician Services Deficiencies
Corrected: Jul 5, 2022
Provide safe, appropriate pain management for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 5, 2022
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 5, 2022
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 5, 2022
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 5, 2022
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 5, 2022
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 5, 2022
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 10.0% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 5.6% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 2.5% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 3.1% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 7.9% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 1.5% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 98.8% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.9% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | N/A | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 31.9% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 100.0% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 0.9% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 19.2% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 10.4% | Yes |
Penalty History 2 penalties totaling $20K
| Date | Type | Amount |
|---|---|---|
| Feb 26, 2024 | Fine | $14K |
| May 30, 2023 | Fine | $6K |
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Frequently Asked Questions
What is the overall CMS rating for ENCORE AT WINDSOR HILLS?
What are the staffing levels at ENCORE AT WINDSOR HILLS?
How many beds does ENCORE AT WINDSOR HILLS have?
Does ENCORE AT WINDSOR HILLS have any deficiencies on record?
Has ENCORE AT WINDSOR HILLS received any fines or penalties?
Who owns ENCORE AT WINDSOR HILLS?
When was ENCORE AT WINDSOR HILLS last inspected?
What quality measures are tracked for ENCORE AT WINDSOR HILLS?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.