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Cadia Rehabilitation Capitol

1225 Walker Road, Dover, DE 19904 · For profit - Limited Liability company · 120 certified beds · (302) 734-1199 Medicare & Medicaid certified

Call the home — (302) 734-1199 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Dec 2024Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$8,018 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2024
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,018 in federal fines (most recent 2024-07-16)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1151 Walker Rd · (302) 674-1299 · Call to confirm hours
Pharmacy
160 Greentree Dr Ste 101 · (888) 627-4515 · Call to confirm hours
Grocery
25 Greentree Dr · (302) 678-4734 · Call to confirm hours
Park
(302) 674-7541 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased13.2%12.7%15.4%better
Long-stay residents who lose too much weight7.8%5.4%5.4%worse
Long-stay residents with a catheter left in their bladder0.5%0.4%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.7%2.1%2.0%better
Long-stay residents with depressive symptoms1.0%10.3%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.6%3.2%3.3%better
Long-stay residents whose ability to walk worsened8.0%13.6%16.1%better
Long-stay residents on antianxiety or hypnotic medication20.6%21.8%18.9%typical
Long-stay residents given the seasonal flu vaccine75.2%97.4%95.3%worse
Long-stay residents with pressure ulcers3.0%3.5%4.7%better
Long-stay residents with worsening bladder/bowel control22.0%20.2%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table10.3%10.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.0%1.4%better
Short-stay residents given the seasonal flu vaccine18.7%83.1%79.4%worse
Short-stay residents rehospitalized after admission28.6%23.3%22.6%worse
Short-stay residents with an outpatient ER visit11.4%11.6%12.0%typical
Long-stay hospitalizations per 1,000 resident days2.301.811.67worse
Long-stay outpatient ER visits per 1,000 resident days0.791.401.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

52.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 120 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

52.0%U.S. median 51.5%
Got home and stayed home
10.0%U.S. median 10.7%
Went back to hospital
37.8%U.S. median 56.6%
Met the expected recovery
0.48U.S. median 0.31
Therapy hours / resident / day
0.23hours / resident / day
Physical therapy
0.22hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 37.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 45 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.48 therapist hours per resident per day in 2026Q1 — more than 79% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 25% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF52.0%CMS range 44.0–61.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.0%CMS range 7.3–13.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge37.8%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge28.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge33.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting85.7%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.3%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.5%CMS range 4.1–10.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.001.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.71
RN hours/ resident / day
1.01
LPN hours/ resident / day
2.15
Aide hours/ resident / day
3.87
Total nurse hours/ resident / day
0.36
RN hoursweekends
45.8%
Total nursing turnover
42.9%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 103.5 residents a day — about 86% occupied, or roughly 16 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.87 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.71 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.15 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.43 hrs/resident/day on weekends vs 4.05 on weekdays — 15% thinner on weekends. RN hours go from 0.85 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

6
deficiencies at the latest standard inspection (2026-01-27)
7
at the previous standard inspection (2024-12-12)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

31 citations, most serious first. The 12 most serious are shown; the remaining 19 are one tap away and print in full.

  • Immediate jeopardy · J2026-01-27 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, it was determined that for one (R5) out of nine residents reviewed for medication administration, the facility failed to ensure that R5 received the correct dose of morphine sulfate for pain when R5 erroneously received 15 mL (milliliter) of the concentrated morphine sulfate oral solution instead of the physician prescribed dose of 0.25 mL on 12/7/25 at 10:58 AM. With this significant medication error, R5 was at risk of a severe, life-threatening respiratory depression or death. R5 was administered Naloxone 0.4 mg/mL intramuscularly two times to reverse R5's overdosage on 12/7/25 at 4:13 PM and 8:02 PM. An immediate Jeopardy (IJ) was identified starting 12/7/25. Due to the facility's corrective measures following the last incident, this is being cited as immediate jeopardy, past non - compliance with an abatement date of 12/11/25. Findings include: A facility policy titled Medication Administration, dated 1/13/26, documented, It is the policy of this facility to ensure that all medications are administered safely, accurately, timely, and in…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Past Non-Compliance
  • Actual harm · Gcited before2024-07-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review and review of other facility documentation it was determined that for one (R1) out of three residents reviewed for accidents the facility failed to provide adequate supervision to prevent an accident. R1, a totally dependent resident was rolled out of bed when a staff person lost grip on R1 during care. R1 rolled from the bed and fell three (3) feet to the floor sustaining a laceration to the head and was emergently transported to the hospital, this resulted in harm to R1. 6/6/17 - R1 was admitted to the facility with diagnoses of but not limited to unspecified dementia (a brain disorder with memory loss), sarcoidosis (an inflammatory disease) and aphasia (neurological condition affecting language). 5/20/24 - An annual MDS documented R1 as totally dependent for self-care, bed mobility and was severely impaired cognition. 6/3/24 - R1's care plan included that the resident was at risk of falls and interventions included: anticipate and meet the resident's needs. 6/1/24 - 6/12/24 - A review of CNA documentation revealed R1 was totally dependent on…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2026-01-27 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, it was determined that for two (R30 and R108) out of nine residents sampled for abuse, the facility failed to report an allegation of abuse to the state agency within two hours. Findings include:2. Review of R108's clinical record revealed: 10/26/25 - E7 (CNA) documented in a written statement, On October 25, 2025 .around 11:15 PM I went to check on all my patients. When I got to [R108] she stated that 'the CNA that had her torn her clothes and was rough with her . 10/26/25 11:08 AM - The facility submitted an allegation of staff to resident abuse incident involving R108 to the state agency, greater than two hours after R108's initial report to the facility. 1/23/26 10:19 AM - During an interview E7 (CNA) confirmed the aforementioned written statement and that R108's allegation of abuse was reported to a nurse on 10/25/25. 1/23/26 1:57 PM - During an interview E3 (ADON) confirmed the finding. E3 stated, I found out through reading notes and things that it happened on the 25th but no one made leadership aware. 1/27/26 5:45 PM - Findings were…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-27 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, it was determined that for one (R5) out of three residents reviewed for PASRR (Preadmission Screening and Resident Review), the facility failed to refer R5 for a PASRR evaluation as required when a resident experiences a significant change in mental health status. Findings include: Review of R5's clinical record revealed:2/6/23 - R5 was re-admitted to the facility. 11/13/23 - R5's Notice of PASRR Level II Outcome indicated that R5 had the following mental health diagnoses: -Adjustment Disorder with depressed mood-Delusional Disorder-Dementia-Mood Disorder NOS (not otherwise specified) -Anxiety Disorder NOS-Psychotic Disorder NOS-Insomnia-Major Depressive Disorder, recurrent, severe, with psychotic symptoms2/14/25 - R5's quarterly MDS (Minimum Data Set) assessment revealed R5's new psychiatric/mood disorder diagnoses including bipolar disorder, adjustment disorder with mixed anxiety and depressed mood and unspecified mood affective disorder. 3/25/25 - R5's significant change MDS assessment revealed R5's psychiatric/mood disorder diagnoses…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-27 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review it was determined for one (R6) out three residents sampled for respiratory care the facility failed to provide professional standards of practice by ensuring R6's BiPap equipment was stored in a protective plastic bag when not in use. Findings include:A review of R6's clinical record revealed:1/10/24 - R6 was admitted to the facility with diagnoses of acute respiratory failure and interstitial pulmonary disease.12/28/25 - A quarterly MDS documented that R6 was cognitively intact.1/20/26 - A physician's order documented BIPAP application at bedtime (HS) and PRN. The order specified: BIPAP setting: 10 cm H O with O bleed-in at 2 liters.1/26/26 - A review of the treatment administration record lacked evidence of an order directing that the BIPAP mask and tubing be stored in a protective plastic bag when not in use.1/20/26 at 10:11 AM - R6's BIPAP mask was observed lying on the bedside table, with the tubing on the floor.1/21/26 at 8:40 AM - R6's BIPAP mask was again observed lying on the bedside table, with the tubing on the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-27 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview it was determined that for one (R81) out of five residents reviewed for unnecessary medication review the facility failed to implement the MRR policies when recommendations made by the pharmacist and agreed by the provider were not completed by the facility. Findings include: The facilities Pharmacist monthly drug review policy last updated 1/23/26 indicated, Facility will encourage physician/prescriber or other responsible parties and the DON to act upon the recommendations contained in the monthly drug review.Review of R81's clinical record revealed:5/15/25 - R81 was admitted to the facility with multiple diagnoses including dementia with behavioral disturbance, anxiety, depression and an allergy to bee venom. 5/30/25 - An MRR recommended an EpiPen be considered related to R81's bee venom allergy, and that R81's Risperdal prescribed for major depressive disorder was an inappropriate use for an antipsychotic. The recommendations were marked as agreed by R81's physician. 6/29/25 - An MRR recommended an EpiPen be considered related to R81's bee…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-27 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview it was determined that the facility failed to maintain accurate and complete records for one (R119) out of three residents reviewed for beneficiary notification. Findings include:Review of R119's medical record revealed:7/25/25 - The facility provided a Notice of Medicare Non-Coverage (NOMNC) to R119 to relay that services would end on that date.1/23/26 - During the beneficiary notification review, a review of R119's worksheet and relevant documents lacked evidence of the second page, the signature page to validate the resident or their responsible party received and understood the notice.1/23/26 1:15 PM - During an interview, E6 (SW) confirmed the finding and relayed that the facility was unable to locate R119's signature page to their NOMNC.1/27/26 5:45 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2 (DON).

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-12-12 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and facility policy review, the facility failed to ensure that beard guards were worn during food production in accordance with professional standards for food service safety and failed to store food in accordance with professional standards for service safety with the potential to affect 109 of 109 residents who consumed food from the kitchen. This failure had the potential for physical contamination of the food in the facility. Findings include: 1. Review of the facility's policy titled, Dress Code dated August 30, 2017, revealed sanitary food preparation staff must wear: hair net or a disposable hat while on duty. Any employee with facial hair must wear a beard guard. During observation of the lunch meal preparation on 12/09/24 at 11:45 AM, two male Dietary Aide (DA)2 and DA 3 with beards did not have beard nets covering their beard at the food preparation station. During observation of the dinner meal preparation on 12/09/24 at 4:45 PM, DA2 and DA3,with beards did not have beard nets covering their beard at the food preparation station. During…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-12 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to ensure one of 29 residents (Resident (R) 39 reviewed had their call light accessible for use creating the potential for needs not to be met. Findings include: Review of the admission Record located under the Profile tab in the electronic medical record (EMR) revealed R39 was initially admitted on [DATE] with diagnoses that included adjustment disorder with depressed mood, congestive heart disease, chronic kidney disease stage three, and gout. Review of the annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/29/24 revealed R39 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R39 was moderately cognitively impaired. On 12/09/24 at 12:44 PM, R39 was in bed and the call light was underneath his bed. On 12/09/24 at 1:09 PM, R39 was observed in bed and the call light was underneath the bed. During an interview at the time of the observation. R39 said he did not know where the call…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-12 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to ensure two (Residents (R) R71 and R37 ) of six residents reviewed for abuse, were free from resident-to resident abuse for two separate incidents. This had the potential to affect resident safety at the facility. Findings include: Review of the facility's abuse policy titled, Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime, revised January 12, 2023, indicated, . It is the policy of Cadia Healthcare to protect residents and prevent occurrences of abuse . 1. Review of R52's electronic medical record (EMR) revealed a Face Sheet located under the Profile tab indicated the resident was admitted to the facility on [DATE] with diagnosis of depression, dementia, anxiety disorder and Alzheimer's. Review of the quarterly Minimum Data Set (MDS) located under the MDS tab with an Assessment Reference Date (ARD) of 11/09/24 indicated a Brief Interview for Mental Status (BIMS) score of 0 out of 15…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-12 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to ensure an incident of resident-to-resident abuse was reported to the State Agency (SA) within two hours of the incident as required for one residents (R)71) from six residents reviewed for abuse. Findings include: Review of the facility's policy titled, Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime, revised January 12, 2023, indicated, . It is the policy of Cadia Healthcare to protect residents and prevent occurrences of abuse .Guidelines .Reporting and Response .Allegations of resident abuse shall be reported to the appropriate state regulatory authority within 2 hours . 1 Review of R52's electronic medical record (EMR) revealed a Face Sheet located under the Profile tab indicated the resident was admitted to the facility on [DATE] with diagnosis of depression, dementia, anxiety disorder and Alzheimer's. Review of the quarterly Minimum Data Set (MDS) located under the MDS tab with an…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-12 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview and policy review, the facility failed to complete a through investigation of an allegation of abuse for one of six residents (Resident (R) 11) reviewed for abuse and neglect out of a total sample of 29. This failed practice had the potential to affect resident safety at the facility. Findings include: Review of R11's electronic medical records (EMR) revealed the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/23/24 found under the MDS with an admission date of 03/26/23 and a Brief Interview for Mental Status (BIMS) score of 15 out 15 which indicated R11 was cognitively intact. Interview on 12/10/24 at 8:43AM, R11 stated that he has never had any problems with staff at the facility. R11 also stated that no one has ever been rough with him during care, and no one has ever pulled on his testicles. During an interview on 12/12/24 at 9:30AM, the Director of Nurses (DON) stated that R11 reported on 01/11/24 that while receiving care on 12/25/24, Certified Nurse Aide (CNA)9 was rough with him during care; forcefully pulling…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · Dcited before2024-12-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure one of 29 residents (Resident (R) 29 reviewed had a mattress that fit the bed frame. The failure created the potential for an injury if R29 's feet became tangled in the gap between the mattress and the footboard of the bed. Findings include: Review of the admission Record located under the Profile tab in the electronic medical record revealed R29 was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following a cerebral infarction, and disorders of bone density and structure. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/19/24 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R29 was cognitively intact. On 12/10/24 at 11:56 AM, R29 was observed in bed with the head of the bed in an upright position. A large gap, which measured 11 inches from the mattress to the footboard was observed. The footboard was noted to be…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-12 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 29 sample residents (Resident (R) 50 had an alternative call light device available when the call light system malfunctioned. The failure created the potential for the resident's care needs to be unmet. Findings include: Review of the admission Record located under the Profile tab in the electronic medical record (EMR) revealed R50 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, congestive heart failure with hypoxia, and interstitial pulmonary disease. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/03/24 revealed a Brief Interview for Mental Status (BIMS) score of six out of 15 which indicated R50 was severely cognitively impaired. Observation on 12/11/24 at 10:46 AM, R50 had no call light plugged into the wall unit, or a substitute call device available. R50 stated, I haven't had one, the other one broke. When asked how she would call…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-08 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, it was determined that for two (R98 and R417) out of twenty-nine residents reviewed for resident assessment, the facility failed to accurately complete MDS assessments to reflect resident status. Findings include: 1. Review of R98's clinical record revealed: 5/9/23 - R98 was readmitted to the facility with dementia. 5/10/23 1:00 AM - A provider progress note documented that R98 was, referred from home to Cadia for LTC (long term care) due to progressive dementia. 5/11/23 - R98's care plan included that R98 had impaired cognitive function or impaired thought process related to dementia. 5/17/23 - R98's admission MDS assessment did not include R98's diagnosis of dementia. 5/31/23 12:42 PM - A psychiatric progress note documented that R98 had a diagnosis of dementia with behavioral disturbances. 8/15/23 1:00 AM - A provider progress note documented a history of dementia. 8/17/23 - R98's quarterly MDS assessment did not include R98's diagnosis of dementia. 11/7/23 10:44 AM - During an interview, E26 (RNAC) confirmed that R98's admission and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-08 · tag F0644 — pattern
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, it was determined that for four (R30, R38, R40 and R74) out of five residents reviewed for PASARR, the facility failed to ensure that a referral for a PASARR screening was completed following a new diagnosis of psychotic disorder which was not listed on the previous PASARR. Findings include: 1. Review of R30's clinical record revealed: 3/7/18 - R30 was admitted to the facility. 3/6/18 - A review of R30's medical record revealed that R30 had a PASARR level I that indicated R30 had a documented serious mental illness (mood disorder with depressive features) and demonstrated a full level II was not indicated at that time. 9/17/18 - A review of R30's medical record revealed that R30 had a PASARR level I.5 that indicated R30 had a documented serious mental illness (mood disorder with depressive features) and demonstrated a full level II was not indicated at that time. 9/7/22 - A review of R30's medical record revealed that R30 has the following new diagnoses: major depressive disorder, delusional disorder, hallucinations, and adjustment disorder with…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-08 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, it was determined that for three (3) (R40, R89, and R514) out of twenty nine residents reviewed for care plans, the facility failed to develop and implement a comprehensive person-centered care plan for an identified need. Findings include: 1. Review of R40's clinical record revealed: 2/7/17 - R40 was admitted to the facility. 2/26/21 - A comprehensive care plan was initiated for R40's verbally aggressive behavior with the following interventions: allow 10-15 minutes to calm down then reapproach; explain all procedures; and identify triggers that cause outbursts. 10/1/22 - A review of R40's medical diagnoses revealed a diagnosis of dementia unspecified severity with agitation. 5/14/23 - A review of R40's MDS revealed that R40 had a diagnosis of non-alzheimers dementia. 11/1/23 10:25 AM - A review of R40's progress notes revealed R40 was receiving services from psychology related to dementia and bipolar disorder. 11/3/23 2:03 PM - An interview with E21(LPN) revealed that care and interventions are based on a care plan and if a resident does not…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-08 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, it was determined that for four (R7, R20, R56, and R87) out of twenty-nine residents reviewed for care plans, the facility failed to ensure the care plan was revised to reflect current care needs. For R7 and R20, the facility failed to have the required members present for the IDT (interdisciplinary team) meeting. Findings include: 1. Review of R56's clinical record revealed the following: 11/22/21 - R56 was admitted to the facility. A care plan for R56 was documented for having a potential/actual impairment impaired mobility with a goal of [R56] will have no complications r/t (related to) DTI (deep tissue injury of the second tow through the review date was initiated on 9/29/22 and revised on 10/21/22. 6/12/23 at 2:52 PM - A nurse's note revealed the following: Resident was noted to have an open area on left foot second toe. Measurement 1.50cm X 0.6cm. Area was measured, dressed and NP and unit manager was informed. 7/24/23 - Bilateral arterial duplex scans completed and revealed no doppler flow detected in left posterior tibialis artery and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-08 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, it was determined that for one, (R7), out of three residents reviewed for (ADLs) for activities of daily living, the facility failed to ensure that residents who are unable to carry out ADLs received the necessary services to maintain good grooming. Findings include: 1. 4/3/23 - R7 was admitted to the facility following a stroke. 4/8/23 - An admission MDS documented R7 as needing one person extensive assistance with grooming. 10/30/23 approximately 10:00 AM - During an observation and subsequent interview, R7's fingernails were long and he was unshaven. R7 stated that he would like to have his finger nails trimmed and to be shaved. 11/2/23 1:06 PM - During an interview, at R7's bedside E12 (CNA) confirmed that finger nails on both hands were long and R7 would like them trimmed. E12 stated, I'll trim them, and I'll shave him. E12 also confirmed that grooming was part of providing care. 11/2/23 through 11/6/23 - Multiple observations of R7 revealed that his finger nails had not been trimmed and he was unshaven. 11/6/23 1:15 PM -…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-08 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, it was determined that for two (R58 and R87) out of twenty-nine (29) residents reviewed for quality of care, the facility failed to follow physician orders. Findings include: 1. Review of R58's clinical record revealed: 8/8/22 - R58 was admitted to the facility with dementia. 9/15/23 12:29 AM - A nursing progress note documented, Resident [R58] in roommate's bed hitting him, trying to make him get out of his bed. Staff attempted to redirect resident to his bed, however, resident punched and kicked staff. 9/15/23 11:24 AM - A Physician order included: Resident (R58) placed on 1:1 (one to one) supervision. 11/1/23 3:35 PM - During an interview E3 (CNO) confirmed the facility lacked evidence of one-to-one supervision implemented following a resident-to-resident altercation. 2. Review of R87's clinical record revealed: 3/7/22 - R87 was admitted to the facility. 12/8/22 - A physician's order was written for R87 to get out of bed daily at lunch time. 5/31/23 - A quarterly MDS revealed that R87 is totally dependent for transfer with hoyer…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-08 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, it was determined that for one (R58) out of six residents reviewed for unnecessary medications, the facility lacked evidence of a gradual dose reduction (GDR) and qualifying diagnosis for R58's physician prescribed antidepressant. Findings include: A facility policy (effective 6/23, last revised 4/29/21 and reviewed on 1/20/23) documented, It is the policy of Cadia Healthcare that residents receive only those psychoactive medications, in the doses and the duration that is clinically necessary to treat the resident's condition. 1. Review of R58's clinical record revealed: 8/8/22 - R58 was admitted to the facility with dementia. 7/19/23 - A pharmacy recommendation to the Physician documented, This resident [R58] is receiving therapy with Trazadone 50 mg QHS (an antidepressant at bedtime) for insomnia since 11/11/22. Federal guidelines require periodic dose reduction trials in an attempt to minimize or discontinue medications that are unnecessary. Please consider a trial dose reduction. The Physician response was to decrease the medication. 7/26/23…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-08 · tag F0791 — failed to provide routine dental services — pattern
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, it was determined that for four (R5, R39, R40 and R66) out of six sampled residents for dental services, the facility failed to assist the residents in obtaining routine dental services. Findings include: A facility policy and procedure titled, Dental Services Available to Residents, with last reviewed of 1/20/23, documented, Routine dental care includes, but is not limited to, initial evaluation of the resident's dental needs; consultation with the resident, family, responsible party, staff, guardian and dental consultant as needed. A facility policy titled, Dental Services Available to Residents last revised on 1/20/23 documented, It is the policy of Cadia Healthcare to ensure that residents have access to contracted Dental Services . Dental Services are coordinated for each resident as needed and requested and include routine and emergent dental care. 1. Review of R5's clinical record revealed the following: 3/30/22 - R5 was admitted to the facility. 3/30/22…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-08 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and document review, it was determined that the facility failed to ensure safe sanitary storage of food, maintain food preparation equipment and kitchen area in a sanitary condition, and maintain food temperature logs. Findings include: 10/30/23 9:53 AM - A build up of dried food residue was discovered around the cutting surface of the stationary can opener. 10/30/23 10:03 AM - The ice scoop was stored on top of the ice inside of the ice machine and a tomato based frozen entrée was discovered with a large portion of the foil lid peeled back exposing the frozen food to contamination from dirt and other debris. 10/30/23 10:15 AM - Significant amounts of dust and other debris were noted inside and suspended from the openings in the air vents located in the kitchen ceiling. 10/30/23 11:57 AM - During a review of the food temperature logs, forty-three (43) meals out of two hundred seventy-six (276) reviewed for temperatures had no temperatures recorded. Temperatures of cooked foods and cold ready to eat foods were not being consistently recorded prior to being…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-08 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on document review, it was determined that the facility failed to have acceptable measures in place to prevent the growth of Legionella and other opportunistic waterborne pathogens. Findings include: 11/6/23 9:22 AM- Document review revealed that the facility did not have a comprehensive water management plan based on nationally accepted standards (e.g., ASHRAE, CDC, or EPA), including a flow diagram with narrative text depicting areas where Legionella and other opportunistic waterborne pathogens could grow and spread, facility specific measures to prevent the growth of opportunistic waterborne pathogens in the building's water system, methods the facility uses to monitor the prevention measures that are in place, and established steps to intervene when control limits are not met. 11/8/23 2:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (CNO) and E4 (COO) during the exit conference.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-08 · tag F0943 — pattern
    Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, it was determined that for one (E18) out of twelve staff being sampled for abuse training, the facility failed to ensure that E18 received the annual abuse training. Findings include: 11/2/23 1:54 PM - Surveyor requested that E1 (NHA) and E3 (CNO) complete the Annual Training/Vaccination Form. 11/3/23 untimed - Results received and reviewed by surveyor. 11/3/23 12:45 PM - In an interview, E3 stated that E18 (COTA) was a transfer from another facility. Her last training had occurred in August 2022 and, as such, is overdue for 2023. 11/3/23 approximately 3:00 PM - E3 provided updated abuse training documentation, which was completed by E18 on 11/3/23. 11/8/23 2:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (CNO) and E4 (COO) during the exit conference.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-08 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, it was determined that for one (R90) out of two residents reviewed for dignity, the facility failed to ensure care was provided in a way that promoted dignity and respect. Findings include: 7/1/22 - R90 was admitted to the facility with degenerative disease of the back. 11/1/23 11:04 AM - During an observation R90 was ambulating in the front hallway of the facility, by the lobby, with E25 (PTA) wearing a night shirt and no pants. R90's upper thighs and incontinence brief was visible to residents, staff and visitors. 11/1/23 11:06 AM - During an interview, E25 (PTA) confirmed that R90's night shirt was bunched up at the waist, and private parts of her body could be seen by others. 11/1/23 11:28 AM - During an interview, E14 (OT) confirmed that she was aware that residents should be appropriately dressed for therapy. E- stated that it would be undignified for a resident to ambulate in the hallway with an ill-fitting night shirt exposing their thighs and brief. E14 stated that she and would have noticed and ensured that the resident was appropriately…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-08 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, it was determined that, for one (R87) out of one resident sampled for activities, the facility failed to ensure that R76 was provided their activity of interest. Findings include: Review of R87's clinical record revealed: 3/7/22 - R87 was admitted to the facility. 3/11/22 - A review of R87's care plan revealed that R87 preferred to have little involvement with activities and chooses not to participate. 11/7/23 10:31 AM - An interview with R87 revealed that R87 wants to participate in bingo when available and wishes to get out of bed to attend this activity. 11/8/23 9:27 AM - A review of R87's activity task log dated 10/24/23 to 11/18/23, revealed R87 attended one bingo out of four bingo activities offered. 11/8/23 9:41 AM - An interview with E20 (Activities Director) confirmed that R87 attended one bingo activity out of four offered in the last sixteen days. E20 confirmed activities were offered but staff are not getting R87 out of bed to attend activities. The facility failed to provide R87 with activity of choice. 11/8/23 2:45 PM - Findings…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-08 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, it was determined that for one (R66) of four residents reviewed for ROM/mobility, the facility failed to provide appropriate services, equipment, and assistance to maintain function/mobility. Findings include: Review of R66's clinical record revealed: 2/8/21 - R66 was admitted to the facility with left sided hemiplegia due to a stroke. 7/22/23 - The annual MDS assessment documented R66 cognitively intact with an impairment on one side for the upper extremities and the lower extremities for her functional range of motion. The MDS also documented R66 required extensive assistance of one staff for dressing. 9/28/23 - An active Physician's order for R66 for a left modified resting hand splint. 10/25/23 - R66's care plan documented the potential for contractures from decreased functional mobility. The interventions for the R66 included to use a left modified resting hand splint. 10/30/23 1:52 PM - During an interview, R66 stated she did not have her splint on yet today and it usually gets put on in the morning and stays on for 7 to 8…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-08 · tag F0790 — failed to provide dental care — isolated
    Provide routine and 24-hour emergency dental care for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, it was determined that for one (R56) out of one sampled resident for dental services, the facility failed to assist the resident in obtaining routine dental services. Findings include: A facility policy titled, Dental Services Available to Residents last revised on 1/20/23 states, as follows: It is the policy of Cadia Healthcare to ensure that residents have access to contracted Dental Services . Dental Services are coordinated for each resident as needed and requested and include routine and emergent dental care. Review of R56's clinical record revealed the following: 11/22/21 - R56 was admitted to the facility. 11/25/21 - The admission MDS assessment documented that R56 had no natural teeth or tooth fragment(s) (edentulous). 11/29/21 - A dental care plan was revised, as follows, [R56] has potential for oral health problems r/t being edentulous (without teeth), poor nutrition, poor oral hygiene Coordinate arrangements for dental care, transportation as needed/as ordered. 10/30/23 9:51 AM - During an interview, R56 stated he was without…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-08 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, it was determined that for one (R34) out of three residents reviewed for food preferences, the facility failed to accommodate R34's food preferences or choices. Findings include: Review of R34's clinical record revealed: 7/7/23 - R34 was admitted to the facility with stroke and multiple sclerosis. 10/12/23 - A quarterly MDS documented R34 had a BIMS score of 14/15, revealing an intact cognitive state. 10/30/23 10:47 AM - During an interview, R34 stated she did not have her menu brought up to make her food choices for this current week. She did not get her menu choices for 10/29/23 and she was served whatever option the kitchen had put on her tray for the day. She said she had spoke to E8 (Food Service Director) about it. 11/3/23 1:17 PM - During an interview, E8 confirmed the menus go from Sunday to Saturday. The menu for the next week is brought up to residents on Thursdays so the residents can make their choices. R34 needs assistance where a dietary aide will circle her choices for her at the bedside. E also confirmed if a menu…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-08 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review and review of other facility documentation, it was determined that the facility failed to ensure, in accordance with professional standards and practices, that medical records for one (R66) out of twenty nine (29) of the investigative sampled residents were accurate. Findings include: Review of R66's clinical record revealed: 2/8/21 - R66 was admitted to the facility with left-sided hemiplegia due to a stroke. 7/22/23 - The annual MDS assessment documented R66 was cognitively intact with an impairment on one side for the upper extremities and the lower extremities for her functional range of motion. The MDS also documented R66 required extensive assistance of one staff for dressing. 9/28/23 - An active Physician's order for R66 for a left modified resting hand splint. 10/25/23 - R66's care plan documented the potential for contractures from decreased functional mobility. The interventions for the R66 included to use a left modified resting hand splint. Observations made of R66 without left resting splint on for 10/30/23, 10/31/23, 11/1/23 and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$8,018 in federal fines across 1 penalty.

  • $8,018 — penalty dated 2024-07-16

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to CADIA HEALTHCARE — 5 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 53.2-0.2 vs chain
Health inspection 3 of 52.6+0.4 vs chain
Staffing 4 of 53.8+0.2 vs chain
Quality measures 4 of 54.4-0.4 vs chain
The other 4 homes this chain runs (chain average 3.2★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
RONALD E SCHAFER IRREV TR FBO ERIC ROBERT SCHAFEROrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/31/2010
RONALD E SCHAFER IRREV TRFBO LAUREN ELIZABETH MARIE SCHAFEROrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/31/2010
SCHAFER FAMILY LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/31/2010
SILVER HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/31/2010
STEPHEN SILVER IRREVOCABLE TRUST FBO CASEY SILVEROrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/31/2010
STEPHEN SILVER IRREVOCABLE TRUST FBO JONATHAN SILVEROrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/31/2010
SCHAFER, ERICIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/31/2010
SCHAFER, LAURENIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/31/2010
SILVER, JONATHANIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/31/2010
LITWA, KARENIndividualCORPORATE OFFICER; TRUSTEE OF THE SNF; ADP OF THE SNFsince 02/01/1997
LONG TERM CARE CORPOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/1997
DITTMAR, LAURAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/13/2024
MAKOYI, FREDDYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2021
PRICE, ELIZABETHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/13/2024
SILVER, STEPHENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/1997
SABRA HEALTH CARE REIT INCOrganizationADP OF THE SNFsince 08/01/2011
SCHAFER, RONIndividualADP OF THE SNFsince 02/01/1997

CMS files one row per role, so the 24 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted.

8 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$14.6M
Net patient revenuemost recent cost report
-0.2%
Operating marginrevenue minus expenses
$1.1M
Related-party expense7% of expenses
Who pays — share of resident-days
Medicaid 75%Medicare 11%Other / private 14%

About 75% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.1M paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$376per resident / day
operating cost
$11,435per month
≈ monthly operating cost
$376per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in DE

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Delaware Medicaid page.

Typical monthly cost in Delaware
$14,494/mo
Nursing home (semi-private)
$15,132/mo
Nursing home (private)
$7,600/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 085048. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-27, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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