Inspection Reports for Cadia Rehabilitation Renaissance

An unannounced Complaint Survey was conducted at the facility from May 28, 2025, through June 2, 2025, based on allegations of abuse involving one resident.

The facility failed to report an allegation of abuse to the state agency for one resident and failed to protect residents by not suspending the accused staff member pending the outcome of the investigation. The facility also failed to remove the accused employee immediately after the allegation was identified.

The complaint investigation was substantiated as the facility did not report an allegation of abuse for resident R15 and failed to suspend the accused staff member pending investigation. The allegation involved staff E10 pushing resident R15. The facility took corrective actions including staff education and audits.

A desk review staffing audit was conducted by the State of Delaware, Division of Health Care Quality, Office of Long-Term Care Residents Protection to assess compliance with minimum staffing levels required by Delaware Code Chapter 11 Nursing Facilities and Similar Facilities.

The facility was found noncompliant with the minimum staffing requirement of 3.28 hours of direct care per resident per day (PPD) based on review of staffing worksheets and ratios. Specifically, the facility failed to maintain the minimum PPD staffing requirement and the minimum CNA day shift staffing ratio of 1:8 during the week of 03/03/25 to 03/09/25.

An unannounced complaint survey and extended survey was conducted at the facility from June 17, 2024 through June 26, 2024 to investigate allegations of abuse and ensure compliance with regulatory requirements.

The facility failed to ensure the protection of all residents from alleged sexual abuse, placing all residents at risk for serious adverse outcomes by not immediately protecting the resident and allowing continued care by the alleged abuser. Corrective actions included suspension of involved staff, mandatory abuse training, and a 90-day probation for the staff member involved.

The complaint investigation found that two residents were subjected to alleged sexual abuse by a CNA. The facility failed to immediately protect the residents and delayed reporting the abuse to the appropriate authorities. The allegation was substantiated with corrective actions taken including suspension and probation of involved staff.

A complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Delaware, Department of Health and Social Services, Division of Health Care Quality to investigate allegations of abuse and neglect at Cadia Rehabilitation Renaissance.

The facility was found not to be in compliance with 42 CFR 483 subpart B due to failure to ensure residents were free from abuse and neglect. Specific incidents involving resident-to-resident altercations and staff verbal abuse were documented, with failure to report alleged abuse within required timeframes.

The complaint investigation substantiated that abuse and neglect occurred involving resident-to-resident physical altercation and verbal abuse by a registered nurse. The facility failed to report the alleged abuse within two hours as required by state law.

The visit was a follow-up desk review staffing audit conducted by the State of Delaware, Division of Health Care Quality, Office of Long-Term Care Residents Protection to assess compliance with minimum staffing levels for nursing services direct caregivers.

The facility was found noncompliant with the minimum staffing requirement of 3.28 hours of direct care per resident per day, with daily staffing levels ranging from 3.02 to 3.17 hours during the review period.

An unannounced Annual and Complaint Survey was conducted at the facility from August 1, 2023 through August 7, 2023 to assess compliance with applicable regulations and investigate complaints.

The facility was found to be out of compliance with minimum staffing requirements, failure to ensure availability of state survey inspection results for residents, failure to timely and thoroughly investigate grievances, failure to develop comprehensive care plans for oxygen use, failure to provide adequate pressure ulcer care, failure to maintain essential kitchen equipment, and failure to ensure accurate medication administration documentation.

The survey included complaint investigation components. Findings included failure to ensure grievances were timely and thoroughly investigated and failure to ensure contact lenses were accounted for and follow-up was conducted.

An unannounced Complaint and Focused Infection Control Survey was conducted from July 8, 2022 through July 13, 2022 to investigate compliance with staffing requirements and infection control.

The facility census was 98 residents with a survey sample size of 10. No deficiencies were identified related to infection control. However, the facility was found to be out of compliance with staffing requirements for 6 of 21 days reviewed, failing to meet the minimum 3.28 hours of direct care per patient per day as required by Delaware Code Chapter 11 Nursing Facilities and the Eagles Law.

The visit was complaint-related and substantiation is implied by findings of non-compliance with staffing requirements. Interviews with facility staff confirmed the failure to meet the 3.28 PPD requirement.

An unannounced annual complaint and emergency preparedness survey was conducted at the facility from October 14, 2021 to October 22, 2021. The survey included observations, interviews, and review of residents' clinical records and other facility documentation.

The survey identified deficiencies related to nursing staffing, resident rights, personal funds management, accuracy of assessments, infection control, medication administration, and other regulatory requirements. The facility failed to meet minimum staffing levels, maintain accurate records, and ensure proper care in several areas. Corrective action plans were outlined to address these deficiencies.

An unannounced COVID-19 Focused Infection Control Survey and Complaint Survey was conducted by the State of Delaware Division of Health Care Quality from August 27, 2021 through August 30, 2021.

The facility was found to be in compliance with 42 CFR §483.80 and had implemented CDC recommended practices to prepare for COVID-19. No deficiencies were identified during the survey.

The survey was complaint-related but no deficiencies were identified, indicating compliance with regulations.

A COVID-19 Focused Infection Control Survey was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection from 2/12/2021 through 2/16/2021 to assess compliance with infection control regulations.

The facility was found to not be in compliance with 42 CFR §483.80 infection control regulations and had not implemented CMS and CDC recommended practices to prepare for COVID-19. Deficiencies included failure to ensure COVID-19 symptom screening for transportation staff entering the building.

A COVID-19 Focused Infection Control Survey and Complaint Survey was conducted by the State of Delaware Division of Health Care Quality from January 12, 2021 through January 15, 2021.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19. No deficiencies were identified at the time of the survey.

A COVID-19 Focused Infection Control survey was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection on November 12, 2020.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19. No deficiencies were identified at the time of the survey.

An unannounced complaint survey was conducted at the facility from March 11, 2019 through March 12, 2019 to investigate allegations related to resident care and safety.

The facility failed to follow a physician's order requiring two staff members to assist a resident (R2) with bed mobility, resulting in a fall and shoulder contusion. The deficiency was based on record review, interviews, and observation.

The complaint investigation found that for one resident (R2) out of four sampled, the facility did not provide the required two staff members for bed mobility assistance as ordered by the physician, leading to a fall and injury. The deficiency was substantiated based on record review and staff interviews.