Inspection Reports for Cadia Rehabilitation Renaissance
26002 John J Williams Highway, Millsboro, DE, 19966
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 2, 2025 identified deficiencies related to failure to report an allegation of abuse and failure to protect residents by not suspending the accused staff member pending investigation. Earlier inspections showed a pattern of issues with staffing levels and resident protection, including substantiated complaints of abuse and delays in reporting. Main themes across reports included inadequate staffing, failure to prevent or promptly report abuse, and incomplete investigations into allegations. Several complaint investigations were substantiated, involving resident abuse and neglect, but enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s deficiencies have persisted over time with repeated staffing shortfalls and resident safety concerns, indicating ongoing challenges without clear improvement.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
6.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% better than Delaware average
Delaware average: 8.8 deficiencies/yearDeficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
107 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 3
Jun 2, 2025
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to report an allegation of abuse to the state agency within required timeframes. | SS=D |
| Failed to investigate and prevent further potential abuse during the investigation. | SS=D |
| Failed to protect residents by not suspending the accused staff member pending the outcome of the investigation. | SS=D |
Report Facts
Census: 107
Survey sample size: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E10 | Certified Nursing Assistant (CNA) | Accused staff member involved in abuse allegation |
| E11 | Certified Nursing Assistant (CNA) | Instructed E8 to write a statement and place it under the DON's door |
| E8 | Certified Nursing Assistant (CNA) | Reported the allegation of abuse |
| E2 | Director of Nursing (DON) | Investigated the incident and was aware of the allegation |
| E7 | Registered Nurse/Unit Manager (RN/UM) | Informed of the incident and began investigation |
| E18 | Registered Nurse (RN) part time supervisor | Wrote statement about resident R15's condition |
| E1 | Nursing Home Administrator (NHA) | Reviewed findings during exit conference |
| E3 | Chief Nursing Officer (CNO) | Reviewed findings during exit conference |
| E4 | Chief Operating Officer (COO) | Reviewed findings during exit conference |
Inspection Report
Plan of Correction
Deficiencies: 2
Mar 21, 2025
Visit Reason
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.
Findings
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.
Deficiencies (2)
| Description |
|---|
| Failed to maintain the minimum PPD staffing requirement of 3.28 hours of direct care per resident per day. |
| Failed to maintain the minimum CNA day shift staffing ratio of 1:8 during the week of 03/03/25 to 03/09/25. |
Report Facts
PPD staffing: 3.06
PPD staffing: 3.1
CNA ratio: 9
Minimum required CNA ratio: 8
Minimum required PPD staffing: 3.28
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 1
Jun 26, 2024
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
SS=: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the protection of residents from alleged sexual abuse and to immediately report and investigate allegations. | SS= |
Report Facts
Survey sample size: 2
Census: 108
PPD (Projected Patient Days): 3.21
PPD (Projected Patient Days): 2.98
PPD (Projected Patient Days): 3.27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E4 | Licensed Practical Nurse (LPN) | Named in abuse allegation and failure to report |
| E5 | Registered Nurse (RN), supervisor | Interviewed regarding abuse allegations |
| E8 | Certified Nurse Assistant (CNA) | Reported abuse allegation and confirmed reporting |
| E9 | Agency CNA | Alleged abuser removed from facility |
| E1 | Nursing Home Administrator (NHA) | Present at exit conference and reviewed findings |
| E7 | Licensed Practical Nurse (LPN), Unit Manager (UM) | Interviewed regarding reporting of abuse allegations |
| E2 | Corporate nurse | Reviewed findings with NHA and others |
| E3 | Corporate nurse | Reviewed findings with NHA and others |
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 2
May 2, 2024
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure two of four residents reviewed for abuse and neglect were free from abuse, including resident-to-resident altercation and verbal abuse by a registered nurse. | SS=D |
| Failure to report alleged abuse within required timeframes to appropriate authorities. | SS=D |
Report Facts
Survey Census: 106
Sample Size: 15
Supplemental Residents: 0
Survey Dates: 04/30/24 to 05/02/24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 1 | Registered Nurse | Named in verbal abuse finding and termination following investigation |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding incident and reporting procedures |
| CNA5 | Certified Nurse Aide | Witnessed resident altercation and provided statements |
Inspection Report
Follow-Up
Deficiencies: 1
Mar 27, 2024
Visit Reason
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.
Findings
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.
Deficiencies (1)
| Description |
|---|
| Failure to provide a staffing level of at least 3.28 hours of direct care per resident per day (PPD). |
Report Facts
PPD staffing levels: 3.1
PPD staffing levels: 3.16
PPD staffing levels: 3.17
PPD staffing levels: 3.07
PPD staffing levels: 3.02
PPD staffing levels: 3.04
Inspection Report
Annual Inspection
Census: 106
Deficiencies: 7
Aug 7, 2023
Visit Reason
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.
Findings
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.
Complaint Details
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.
Deficiencies (7)
| Description |
|---|
| Facility failed to provide minimum staffing level of 3.28 hours of direct care per resident per day. |
| Facility failed to ensure state survey inspection results were available for residents to read. |
| Facility failed to ensure grievances were timely and thoroughly investigated and resolved. |
| Facility failed to develop and implement comprehensive care plan for oxygen use for one resident. |
| Facility failed to ensure pressure ulcer care including turning and repositioning every two hours for one resident. |
| Facility failed to maintain essential kitchen equipment in safe operating condition due to ice buildup in walk-in freezer. |
| Facility failed to ensure accurate and complete medication administration documentation for one resident receiving antibiotics via PICC line. |
Report Facts
Facility census: 106
Survey sample: 22
Staffing hours per resident per day: 3.28
Staffing hours per resident per day: 3
Resident count reviewed for grievances: 1
Residents reviewed for care plans: 22
Resident with pressure ulcer: 1
Resident with oxygen care plan deficiency: 1
Resident with medication administration documentation deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator (NHA) | Named in staffing deficiency findings and exit conference. |
| E2 | Director of Nursing (DON) | Named in staffing deficiency findings and exit conference. |
| E3 | Corporate Representative | Present during exit conference reviewing findings. |
| E4 | Certified Nursing Assistant (CNA) | Interviewed regarding medication administration and oxygen tubing. |
| E5 | Licensed Practical Nurse (LPN) | Interviewed regarding oxygen use and medication administration. |
| E6 | Dietary Director | Interviewed regarding ice buildup in kitchen equipment. |
| E7 | Unit Manager (UM) | Interviewed regarding pressure ulcer care. |
| E8 | Assigned CNA | Interviewed regarding pressure ulcer care. |
| FM1 | Family Member | Interviewed regarding concerns about pressure ulcer care. |
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 1
Jul 13, 2022
Visit Reason
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.
Findings
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.
Complaint Details
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.
Deficiencies (1)
| Description |
|---|
| Failed to provide staffing at a level of at least 3.28 hours of direct care per patient care (PPD) for 6 of 21 days reviewed. |
Report Facts
Facility census: 98
Survey sample size: 10
Days out of compliance: 6
Direct care hours per patient per day: 3.28
Direct care hours recorded: 2.82
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E3 | Scheduler | Confirmed facility was not meeting 3.28 PPD staffing requirement during interview |
| E2 | Corporate | Confirmed facility was not meeting 3.28 PPD staffing requirement during interview and participated in exit conference |
| E1 | Nursing Home Administrator | Signed staffing worksheets and participated in exit conference |
Inspection Report
Annual Inspection
Census: 98
Deficiencies: 26
Oct 22, 2021
Visit Reason
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.
Findings
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.
Severity Breakdown
E: 13
D: 5
B: 2
Deficiencies (26)
| Description | Severity |
|---|---|
| Failure to conspicuously display names and titles of nursing staff direct caregivers and nursing supervisors on duty for each shift. | — |
| Failure to provide adequate nursing staffing levels to meet minimum required hours of direct care per resident per day. | — |
| Failure to provide services in a dignified manner during meal service, including serving meals on trays in the dining room. | Severity Level: E |
| Failure to organize and participate in resident or family groups with private space and timely meetings. | Severity Level: E |
| Failure to notify the Office of the State Long-Term Care Ombudsman of hospital transfers or facility discharges for certain residents. | — |
| Failure to complete accurate Minimum Data Set (MDS) assessments for dental services and other care areas. | — |
| Failure to provide routine and emergency dental services as required. | — |
| Failure to provide a safe, clean, comfortable, and homelike environment, including maintenance of housekeeping and maintenance services. | Severity Level: B |
| Failure to maintain proper food safety standards including temperature control and removal of outdated food. | — |
| Failure to develop and implement comprehensive person-centered care plans including measurable objectives and timeframes. | Severity Level: E |
| Failure to provide adequate care plans for residents on hemodialysis including monitoring for bruit and thrill at access sites. | Severity Level: E |
| Failure to provide adequate care plans for urinary and bowel incontinence including interventions and monitoring. | Severity Level: E |
| Failure to provide adequate care plans for residents with depression including appropriate interventions and follow-up. | Severity Level: E |
| Failure to provide adequate care plans for residents requiring extensive assistance and transfers. | Severity Level: E |
| Failure to provide adequate care plans for residents with pressure ulcers including turning and repositioning. | Severity Level: D |
| Failure to provide adequate care plans for residents with bladder and bowel incontinence including scheduled checks and interventions. | Severity Level: E |
| Failure to provide adequate care plans for residents with diabetes including insulin administration and monitoring. | Severity Level: E |
| Failure to ensure residents are free from significant medication errors including insulin administration timing and monitoring. | Severity Level: D |
| Failure to maintain proper storage and temperature control of medications and biologicals. | Severity Level: D |
| Failure to maintain accurate and confidential resident records including medical and dental records. | Severity Level: E |
| Failure to provide routine dental services and timely referrals for lost or damaged dentures. | Severity Level: D |
| Failure to maintain infection prevention and control program including hand hygiene, blood glucose monitoring, and COVID-19 screening. | Severity Level: E |
| Failure to maintain proper food safety including temperature logs and removal of outdated food. | Severity Level: E |
| Failure to maintain safe environment including repair of toilet paper holders, sinks, and removal of dust and debris. | Severity Level: B |
| Failure to maintain privacy during wound care and other personal care activities. | Severity Level: E |
| Failure to ensure residents' rights to dignity, respect, and exercise of rights without interference or coercion. | Severity Level: E |
Report Facts
Facility census: 98
Survey sample size: 51
Staffing hours per resident per day: 3.28
Staffing hours per resident per day: 3.22
Staffing hours per resident per day: 3.25
Medication error rate: 5
Medication errors identified: 2
Temperature range: 36
Temperature range: 46
Temperature exceedances: 18
Temperature exceedance percentage: 62
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 0
Aug 30, 2021
Visit Reason
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.
Findings
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.
Complaint Details
The survey was complaint-related but no deficiencies were identified, indicating compliance with regulations.
Report Facts
Survey sample size: 11
Inspection Report
Routine
Census: 90
Deficiencies: 1
Feb 16, 2021
Visit Reason
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.
Findings
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.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility failed to ensure that COVID-19 symptom screening was being conducted for transportation staff entering the building. | SS=E |
Report Facts
Facility census: 90
Survey sample: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Named as participant in exit teleconference and responsible for corrective actions | |
| Nursing Home Administrator (NHA) | Named as participant in exit teleconference and interviewed regarding screening practices |
Inspection Report
Routine
Census: 89
Deficiencies: 0
Jan 15, 2021
Visit Reason
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.
Findings
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.
Report Facts
Facility census: 89
Inspection Report
Routine
Census: 92
Deficiencies: 0
Nov 12, 2020
Visit Reason
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.
Findings
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.
Report Facts
Facility census: 92
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 1
Mar 11, 2019
Visit Reason
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.
Findings
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.
Complaint Details
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.
Deficiencies (1)
| Description |
|---|
| Failure to follow physician's order for two staff members to assist resident with bed mobility, resulting in a fall and shoulder contusion. |
Report Facts
Survey sample size: 8
Facility census: 120
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