Inspection Reports for
Cadia Rehabilitation Renaissance
26002 John J Williams Highway, Millsboro, DE, 19966
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
16 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
82% worse than Delaware average
Delaware average: 8.8 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
82% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 25, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to timely report suspected abuse and misappropriation of resident property, and concerns about medication reconciliation and pharmaceutical services.
Complaint Details
The complaint investigation substantiated that the facility delayed reporting an allegation of misappropriation of resident property and had medication reconciliation discrepancies and pharmaceutical service deficiencies.
Findings
The facility failed to timely report an allegation of misappropriation of resident property and had discrepancies in medication reconciliation documentation for a controlled drug. Additionally, the facility failed to ensure proper labeling and storage of medications, including unlabeled medications accepted from a resident and opened medications without open dates.
Deficiencies (3)
F 0609: The facility failed to timely report an allegation of misappropriation of resident property to the state agency within the required timeframe, delaying the report by nineteen days.
F 0755: The facility failed to ensure accuracy of medication reconciliation documentation for a controlled drug, resulting in a five-capsule deficit without clarification in the records.
F 0761: The facility failed to label opened medications with open dates, store insulin according to manufacturer instructions, and safely secure unlabeled medications accepted from a resident.
Report Facts
Days delayed in reporting misappropriation: 19
Medication capsule deficit: 5
Number of missing purple pills: 6
Medication carts reviewed: 3
Medication carts with unlabeled opened medications: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Former Director of Nursing (DON) | Responsible for reporting the misappropriation allegation and involved in medication storage and incident reporting. |
| E9 | RN Supervisor | Notified the DON about the missing pills and involved in the investigation. |
| E12 | LPN | Documented missing pills and administered medication with discrepancies. |
| E13 | RN | Witnessed medication destruction and confirmed medication record discrepancies. |
| E11 | Chief Nursing Officer (CNO) | Interviewed regarding medication reconciliation discrepancies and pharmaceutical services. |
| E24 | RN | Confirmed acceptance and storage of unlabeled medications from resident R123. |
| E25 | LPN | Confirmed receipt and storage of six purple pills from resident R123. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 2, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an allegation of abuse and to respond appropriately to the alleged violation involving resident R15.
Complaint Details
The complaint investigation involved one resident (R15) with an allegation that a staff member pushed the resident. The allegation was not reported to the state agency as required, and the accused staff member was not suspended pending investigation. The allegation was ultimately determined to be unsubstantiated.
Findings
The facility failed to report an allegation of abuse to the state agency within the required timeframe and did not suspend the accused staff member pending the outcome of the investigation. The investigation found no evidence of abuse, but the facility did not follow policy requirements for reporting and suspension.
Deficiencies (2)
F 0609: The facility failed to timely report suspected abuse to the appropriate state regulatory authority for one resident. The allegation of abuse was not reported within two hours as required by policy.
F 0610: The facility failed to protect residents by not suspending the accused staff member pending the outcome of the abuse investigation. The staff member continued working during the investigation.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Director of Nursing (DON) | Named in the investigation and interview regarding the abuse allegation and investigation. |
| E8 | Certified Nursing Assistant (CNA) | Reported the abuse allegation and wrote a statement placed under the DON's door. |
| E10 | Certified Nursing Assistant (CNA) | Accused staff member alleged to have pushed resident R15. |
| E11 | Licensed Practical Nurse (LPN), supervisor | Instructed staff to write statements but did not report the allegation to the state agency. |
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 3
Date: 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.
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.
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.
Deficiencies (3)
Failed to report an allegation of abuse to the state agency within required timeframes.
Failed to investigate and prevent further potential abuse during the investigation.
Failed to protect residents by not suspending the accused staff member pending the outcome of the investigation.
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
Date: 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)
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
Routine
Deficiencies: 16
Date: Sep 19, 2024
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory requirements including resident rights, care planning, medication management, infection control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during meals, failure to honor resident self-determination, improper use of physical restraints, incomplete care plans, inadequate assistance with activities of daily living, unsafe equipment, incomplete trauma-informed care, medication administration failures, incomplete menu accommodations, deficient arbitration agreements, and infection control protocol breaches.
Deficiencies (16)
F550: Facility failed to ensure residents were provided a homelike dining environment, privacy for catheter bags, and privacy with shower schedules, risking undignified dining experiences.
F561: Facility failed to honor residents' rights to self-determination by not allowing choice in transfer methods and outdoor access, risking psychosocial harm.
F604: Facility applied a Wanderguard and physically restrained a resident against his will, constituting improper use of physical restraints.
F656: Facility failed to develop and implement comprehensive care plans for side rails and weight monitoring for palliative care for two residents, risking decreased quality of life.
F677: Facility failed to maintain an accurate and updated comprehensive care plan for a resident with a pressure ulcer, lacking specific interventions to offload pressure.
F677: Facility failed to provide adequate assistance and cueing for a cognitively impaired resident during meals, increasing risk of weight loss.
F689: Facility failed to provide a safe, stable toilet and commode for a resident, creating potential fall or injury hazards.
F700: Facility failed to assess need for side rails and obtain informed consent for their use for one resident, increasing risk of unmonitored use.
F742: Facility failed to provide trauma-informed care with specific interventions and staff education for a resident with PTSD, risking unmet psychosocial needs.
F755: Facility failed to ensure pharmacy was contacted to provide medications timely, resulting in missed doses of eye drops and supplements for one resident.
F760: Facility failed to ensure residents were free from significant medication errors by missing multiple doses of antibiotics for one resident with tooth abscess.
F761: Facility failed to ensure insulin pens were not expired before administration, risking ineffective treatment for one resident.
F803: Facility failed to provide menu extensions for finger foods for a resident with a finger food diet order, risking inadequate nutrition.
F847: Facility failed to thoroughly explain binding arbitration agreements to residents or representatives and did not provide rescission rights or communication rights with officials for three residents.
F848: Facility failed to provide a neutral and fair arbitration process by limiting arbitrator selection and not providing venue choice for three residents.
F880: Facility failed to develop and implement infection control protocols including proper PPE use, eye protection availability, cleaning of carts, and wound care practices, risking infection spread to residents.
Report Facts
Medication administration opportunities missed: 18
Medication administration opportunities missed: 11
Medication administration opportunities missed: 8
Fall risk score: 6
BIMS score: 4
BIMS score: 13
BIMS score: 2
BIMS score: 6
BIMS score: 8
BIMS score: 0
BIMS score: 14
BIMS score: 14
BIMS score: 3
BIMS score: 0
BIMS score: 11
BIMS score: 12
BIMS score: 3
Resident count: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John J Williams | Facility address name | |
| LPN1 | Licensed Practical Nurse | Named in catheter privacy bag finding and medication cart PPE observation |
| Director of Nursing | DON | Named in multiple interviews regarding catheter privacy, restraint use, care planning, medication, and wound care |
| Certified Nurse Aide 3 | CNA3 | Named in dining environment and resident assistance findings |
| Social Service Director | SSD | Named in resident rights, trauma screening, and restraint interviews |
| Certified Occupational Therapy Assistant | COTA | Named in transfer board and side rail assessment findings |
| Registered Nurse 2 | RN2 | Named in transfer and medication administration interviews |
| Administrator | Named in multiple interviews regarding resident rights, dining, restraint, arbitration agreements, and infection control | |
| Minimum Data Set Coordinator | MDSC | Named in care planning, trauma screening, and side rail care plan interviews |
| Registered Dietitian | RD | Named in nutrition and menu extension interviews |
| Dietary Manager | DM | Named in menu extension interviews |
| Licensed Practical Nurse 4 | LPN4 | Named in wound care infection control observation |
| Nurse Practitioner 2 | NP2 | Named in medication administration interviews |
| Certified Nurse Aide 7 | CNA7 | Named in restraint incident interview |
| Activity Coordinator | AD | Named in resident outdoor access interview |
| Staff Development Coordinator | SDC | Named in infection control interview |
| Activity Aide | AA | Named in infection control observation |
| Certified Nurse Aide 2 | CNA2 | Named in infection control observation |
| Environmental Services Supervisor | EVS | Named in infection control observation |
| Director of Rehabilitation | DOR | Named in infection control and side rail assessment interviews |
| Licensed Practical Nurse 5 | LPN5 | Named in medication administration interview |
| Registered Nurse | RN | Named in medication administration interview |
| Admissions Coordinator | AC | Named in arbitration agreement interview |
Inspection Report
Routine
Deficiencies: 16
Date: Sep 19, 2024
Visit Reason
Routine state inspection survey conducted to assess compliance with regulatory requirements including resident rights, care planning, medication management, infection control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during meals, failure to honor resident self-determination, improper use of physical restraints, incomplete care plans, inadequate assistance with activities of daily living, unsafe equipment and environment, incomplete trauma-informed care, medication administration errors, incomplete menu accommodations, deficient arbitration agreements, and lapses in infection prevention and control.
Deficiencies (16)
F 0550: The facility failed to ensure residents were provided a homelike dining environment, privacy with catheter bags, and shower schedules, affecting multiple residents. Catheter bags were visible from hallways, and meals were served on trays with inappropriate containers.
F 0561: The facility failed to honor residents' rights to self-determination for transfer methods and outdoor access for two residents, placing them at risk of psychosocial harm.
F 0604: The facility applied a Wanderguard restraint and physically pulled a resident back into the facility against his will, constituting an unauthorized physical restraint.
F 0656: The facility failed to develop and implement comprehensive care plans for side rails and weight monitoring for palliative care for two residents, risking decreased quality of life and care.
F 0657: The facility failed to update and individualize a resident's comprehensive care plan for a pressure ulcer, lacking specific interventions such as off-loading the heel.
F 0677: The facility failed to provide adequate dining assistance and cueing for a cognitively impaired resident, increasing risk of weight loss.
F 0689: The facility failed to provide a safe and stable commode for a resident, with a wobbly seat and rusted exposed bars, creating fall and injury hazards.
F 0700: The facility failed to assess the need for side rails and obtain informed consent for a resident, and care plans did not reflect side rail use.
F 0742: The facility failed to provide trauma-informed care with specific interventions and trigger identification for a resident with PTSD, risking unmet psychosocial needs.
F 0755: The facility failed to ensure pharmacy was contacted to provide medications, resulting in missed doses of eye drops and supplements for a resident.
F 0760: The facility failed to prevent significant medication errors by missing multiple doses of antibiotics for a resident with a tooth abscess, risking infection and weight loss.
F 0761: The facility failed to ensure insulin pens were not expired before administration, risking ineffective treatment for a resident.
F 0803: The facility failed to provide menu extensions for finger foods for a resident ordered on a finger food diet, risking weight loss and inadequate nutrition.
F 0847: The facility failed to thoroughly explain binding arbitration agreements to residents or representatives and did not provide rescission rights or communication rights with officials for three residents.
F 0848: The facility failed to provide a neutral and fair arbitration process by limiting arbitrator selection and not specifying a convenient venue for three residents.
F 0880: The facility failed to implement infection control protocols including proper PPE use, eye protection availability, cleaning of carts, and wound care practices, risking infection spread and resident harm.
Report Facts
Medication doses missed: 18
Medication doses missed: 11
Medication doses missed: 8
Medication doses missed: 4
Fall risk score: 6
BIMS score: 4
BIMS score: 13
BIMS score: 2
BIMS score: 6
BIMS score: 8
BIMS score: 0
BIMS score: 14
BIMS score: 14
BIMS score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John J Williams | Administrator | Named in multiple interviews regarding facility policies and deficiencies |
| LPN1 | Licensed Practical Nurse | Named in catheter bag privacy and medication cart PPE use |
| LPN2 | Licensed Practical Nurse | Named in side rail assessment and feeding assistance |
| RN2 | Registered Nurse | Named in medication administration and feeding assistance |
| MDSC | Minimum Data Set Coordinator | Named in care plan and side rail care planning |
| SSD | Social Service Director | Named in trauma screening and resident rights interviews |
| COTA | Certified Occupational Therapy Assistant | Named in side rail assessment and transfer board use |
| DON | Director of Nursing | Named in multiple interviews regarding care and infection control |
| IP | Infection Preventionist | Named in infection control observations and interviews |
| RN | Nurse Practitioner | Named in medication administration interviews |
| AC | Admissions Coordinator | Named in arbitration agreement explanation |
| CRD | Corporate Registered Dietitian | Named in menu and diet order interviews |
| DM | Dietary Manager | Named in menu and diet order interviews |
| HA | Hospitality Aide | Named in dining assistance observations |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 26, 2024
Visit Reason
The inspection was conducted due to allegations of sexual abuse involving two residents (R1 and R2). The investigation focused on the facility's failure to protect residents from abuse and to appropriately report the allegations.
Complaint Details
The complaint involved allegations of sexual abuse by a CNA against two residents. The allegations were substantiated with witness statements and interviews. The facility failed to report the abuse within the required two hours, resulting in immediate jeopardy. Corrective actions were taken including suspension and probation of staff, mandatory training, and notification of authorities.
Findings
The facility failed to ensure protection of residents from alleged sexual abuse by a CNA, resulting in immediate jeopardy to resident health and safety. The facility did not report the abuse allegations within the required two-hour timeframe and allowed the accused CNA to continue working until removed. Corrective actions included suspension and probation of involved staff, mandatory abuse training, and notification of the state agency.
Deficiencies (1)
F 0610: The facility failed to respond appropriately to all alleged violations of abuse. Two residents reported sexual abuse by a CNA, but the facility delayed reporting to nursing management and the state agency, placing residents at risk.
Report Facts
Residents affected: 2
Compliance date: Jun 14, 2024
Dates of interviews: 6
Probation duration: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E4 | LPN | Failed to report abuse allegation to nursing management; suspended and placed on probation. |
| E9 | Agency CNA | Accused of sexual abuse; removed from facility and agency notified. |
| E5 | RN, supervisor | Received delayed report of abuse allegations and notified NHA, DON, and State police. |
| E8 | CNA | Reported abuse allegations to E4 and later to E5. |
| E7 | LPN, UM | Reported abuse allegations to State agency later than required. |
| E1 | NHA | Findings reviewed with. |
| E2 | DON | Notified of abuse allegations and findings reviewed with. |
| E3 | Corporate nurse | Findings reviewed with. |
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
Failure to ensure the protection of residents from alleged sexual abuse and to immediately report and investigate allegations.
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
Deficiencies: 2
Date: May 2, 2024
Visit Reason
The inspection was conducted due to allegations of abuse and neglect involving residents at the facility, including a resident-to-resident altercation and verbal abuse by a staff member.
Complaint Details
The complaint investigation involved two residents: Resident 2 was physically assaulted by Resident 1, and Resident 6 was verbally abused by Registered Nurse 1. The verbal abuse incident was not reported to the state within the required two-hour window. The registered nurse was suspended and subsequently terminated.
Findings
The facility failed to ensure two residents were free from abuse, including a resident-to-resident physical altercation and verbal abuse by a registered nurse. Additionally, the facility failed to timely report an allegation of verbal abuse to the state regulatory authority within the required two-hour timeframe.
Deficiencies (2)
F 0600: The facility failed to protect residents from abuse, including a resident-to-resident altercation where one resident punched and threw a juice cup at another, causing a minor injury. The facility also failed to prevent verbal abuse by a registered nurse toward a resident.
F 0609: The facility failed to timely report an allegation of verbal abuse by a registered nurse to the state regulatory authority within two hours, reporting it approximately six hours after the incident.
Report Facts
BIMS score: 0
BIMS score: 5
BIMS score: 6
Staffing count: 4
Staffing count: 1
Time delay in reporting: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse | Named in verbal abuse finding and subsequent termination. |
| John J Williams | Mentioned as part of facility address, not related to findings. | |
| Director of Nursing | Director of Nursing | Interviewed regarding incidents involving residents and staff. |
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 2
Date: 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.
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.
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.
Deficiencies (2)
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.
Failure to report alleged abuse within required timeframes to appropriate authorities.
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
Date: 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)
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
Date: 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.
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.
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.
Deficiencies (7)
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
Annual Inspection
Deficiencies: 6
Date: Aug 7, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and to identify any deficiencies in resident care and facility operations.
Findings
The facility was found deficient in several areas including failure to make survey results available to residents, incomplete care plans for oxygen use, inadequate pressure ulcer care, improper respiratory care practices, incomplete medication administration records, and failure to maintain essential kitchen equipment safely.
Deficiencies (6)
F 0577: The facility failed to ensure that the state survey inspection results were available for residents to read as the binder in the lobby lacked recent survey results.
F 0656: The facility failed to develop and implement a complete care plan for one resident's oxygen use, lacking physician orders and nursing measures.
F 0686: The facility failed to ensure a resident with a pressure ulcer was turned and repositioned every two hours to promote healing and prevent new ulcers.
F 0695: The facility failed to provide professional standards of respiratory care by not changing oxygen tubing weekly for one resident.
F 0842: The facility failed to ensure accurate and complete medication administration records for one resident, missing documentation of antibiotic administration.
F 0908: The facility failed to maintain essential kitchen equipment safely, with ongoing ice build-up observed in the walk-in freezer.
Report Facts
Residents reviewed for care plans: 22
Residents reviewed for pressure ulcers: 1
Residents sampled for medication records: 21
Braden scale score: 12
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator (NHA) | Confirmed findings during interviews and exit conference |
| E2 | Director of Nursing (DON) | Confirmed findings during interviews and exit conference |
| E3 | Corporate Representative | Participated in exit conference reviewing findings |
| E4 | Licensed Practical Nurse (LPN) | Confirmed lack of physician orders and medication documentation |
| E5 | Licensed Practical Nurse (LPN) | Confirmed no physician orders or nursing measures for oxygen use |
| E6 | Dietary Director | Confirmed ice build-up in walk-in freezer |
| E7 | Utilization Manager (UM) | Interviewed regarding pressure ulcer care and repositioning |
| E8 | Certified Nursing Assistant (CNA) | Interviewed regarding resident repositioning and pressure ulcer care |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 7, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding grievance handling and medication administration documentation at the facility.
Complaint Details
The investigation was complaint-driven, focusing on grievances about missing personal items and incomplete medication records. The grievance related to missing contact lenses was substantiated as the facility lacked evidence of follow-up. The medication documentation deficiency was confirmed through record review and staff interviews.
Findings
The facility failed to ensure timely and thorough investigation of a resident grievance concerning missing personal items. Additionally, the facility failed to maintain accurate and complete medication administration records for one resident.
Deficiencies (2)
F 0585: The facility failed to ensure concerns received were timely and thoroughly investigated to resolve a resident grievance regarding missing contact lenses.
F 0842: The facility failed to maintain accurate and complete medication administration records for one resident, lacking documentation of antibiotic administration on specified dates.
Report Facts
Residents sampled: 21
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NHA | Interviewed regarding grievance follow-up and findings review | |
| DON | Interviewed regarding grievance and medication record findings | |
| Corporate Representative | Participated in findings review | |
| LPN | Interviewed about medication administration procedures | |
| UM | Confirmed medication record deficiencies |
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
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
Routine
Deficiencies: 19
Date: Oct 22, 2021
Visit Reason
Routine state inspection of Cadia Rehabilitation Renaissance nursing home to assess compliance with regulatory requirements including resident rights, care planning, medication administration, infection control, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to provide dignified services during meals, inadequate response to resident council concerns, improper handling of resident personal funds, failure to protect resident privacy, unsafe environment maintenance, lack of timely notification to Ombudsman, inaccurate resident assessments, incomplete care plans, failure to provide incontinence care as planned, medication errors related to insulin administration timing, improper storage of refrigerated medications, failure to provide routine dental services, inaccurate resident records, and lapses in infection prevention and control practices.
Deficiencies (19)
F 0550: Facility failed to provide services in a dignified manner during meal service on one unit, including serving meals on trays and inadequate staff engagement with residents.
F 0565: Facility failed to promptly act upon and respond to Resident Council grievances and recommendations regarding dining services and call bell response times.
F 0571: Facility failed to ensure resident personal funds were not billed for non-covered services, including hair salon fees.
F 0583: Facility failed to protect personal privacy for residents during care and activities, including failure to close doors during wound care and exposure of residents in shower chairs.
F 0584: Facility failed to maintain a safe, clean, and homelike environment, including loose toilet paper holders, wall-mounted sinks, wall damage, and dusty wires in resident rooms.
F 0623: Facility failed to notify the Ombudsman of hospital transfers or discharges for a resident as required.
F 0641: Facility failed to complete an accurate MDS assessment for a resident's dental status, missing broken and missing teeth.
F 0656: Facility failed to develop comprehensive care plans for residents' active conditions including hemodialysis and depression.
F 0657: Facility failed to ensure required interdisciplinary team members provided input for comprehensive care plans for multiple residents.
F 0677: Facility failed to provide incontinence care as per care plans and failed to identify decline in transfer function for a resident.
F 0684: Facility failed to monitor fluid intake for a resident on a fluid restriction, including exceeding prescribed limits and incorrect fluid amounts offered.
F 0686: Facility failed to provide appropriate pressure ulcer care, including failure to follow physician's wound care orders and failure to reposition a resident as prescribed.
F 0689: Facility failed to identify a decline in transfer status for a resident, placing the resident at risk for injury.
F 0759: Facility failed to ensure medication error rates were below 5%, with insulin administered too far in advance of meals increasing risk of hypoglycemia.
F 0761: Facility failed to ensure refrigerated drugs and biologicals were stored at proper temperatures, with repeated temperature readings above acceptable range.
F 0791: Facility failed to assist residents in obtaining routine dental services, with lack of evidence of dental consults or services for residents with dental issues.
F 0812: Facility failed to maintain consistent food temperature logs, maintain safe refrigerator temperatures, and dispose of outdated food in the kitchen.
F 0842: Facility failed to ensure resident records were accurate, including inaccurate documentation of incontinence care, transfer assistance, and misfiled hospice documents.
F 0880: Facility failed to establish and maintain an infection prevention and control program, including failure to follow hand hygiene and glove use protocols during insulin administration and failure to actively screen staff for COVID-19 symptoms.
Report Facts
Meals served without temperature recorded: 504
Meals served with incomplete temperature info: 20
Medication error rate: 8
Days with refrigerator temperature above 46°F: 18
Days with refrigerator temperature above 46°F: 16
Days fluid intake exceeded restriction: 11
Additional days fluid intake exceeded restriction: 4
Staff not actively screened for COVID-19 symptoms: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | NHA | Named in multiple findings including meal service, personal funds, privacy, Ombudsman notification, infection control, and staff screening |
| E2 | DON | Named in multiple findings including meal service, personal funds, privacy, Ombudsman notification, care planning, medication errors, infection control |
| E8 | RN | Observed administering insulin and involved in medication error and infection control findings |
| E10 | RN, UM | Interviewed regarding meal service, transfer assistance, and record accuracy |
| E18 | Food Service Director | Interviewed regarding food temperature and kitchen findings |
| E29 | Maintenance Director | Interviewed regarding refrigerator temperature issues |
| E20 | SSD | Interviewed regarding dental services |
| E23 | CNA | Observed in transfer and incontinence care findings |
| E24 | CNA | Observed in transfer and incontinence care findings |
| E25 | PT | Conducted transfer assessment for resident R1 |
Inspection Report
Annual Inspection
Census: 98
Deficiencies: 26
Date: 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.
Deficiencies (26)
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.
Failure to organize and participate in resident or family groups with private space and timely meetings.
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.
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.
Failure to provide adequate care plans for residents on hemodialysis including monitoring for bruit and thrill at access sites.
Failure to provide adequate care plans for urinary and bowel incontinence including interventions and monitoring.
Failure to provide adequate care plans for residents with depression including appropriate interventions and follow-up.
Failure to provide adequate care plans for residents requiring extensive assistance and transfers.
Failure to provide adequate care plans for residents with pressure ulcers including turning and repositioning.
Failure to provide adequate care plans for residents with bladder and bowel incontinence including scheduled checks and interventions.
Failure to provide adequate care plans for residents with diabetes including insulin administration and monitoring.
Failure to ensure residents are free from significant medication errors including insulin administration timing and monitoring.
Failure to maintain proper storage and temperature control of medications and biologicals.
Failure to maintain accurate and confidential resident records including medical and dental records.
Failure to provide routine dental services and timely referrals for lost or damaged dentures.
Failure to maintain infection prevention and control program including hand hygiene, blood glucose monitoring, and COVID-19 screening.
Failure to maintain proper food safety including temperature logs and removal of outdated food.
Failure to maintain safe environment including repair of toilet paper holders, sinks, and removal of dust and debris.
Failure to maintain privacy during wound care and other personal care activities.
Failure to ensure residents' rights to dignity, respect, and exercise of rights without interference or coercion.
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
Date: 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.
Complaint Details
The survey was complaint-related but no deficiencies were identified, indicating compliance with regulations.
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.
Report Facts
Survey sample size: 11
Inspection Report
Routine
Census: 90
Deficiencies: 1
Date: 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.
Deficiencies (1)
The facility failed to ensure that COVID-19 symptom screening was being conducted for transportation staff entering the building.
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
Date: 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
Date: 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
Date: 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.
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.
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.
Deficiencies (1)
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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