Cadia Rehabilitation Silverside
3322 Silverside Road, Wilmington, DE 19810 · For profit - Limited Liability company · 116 certified beds · (302) 478-8889 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (5/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has abuse, neglect, or exploitation citations (F0600, F0609) — most recent Mar 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- inspectors recorded 1 serious finding 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 (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $10,608 in federal fines (most recent 2025-03-27)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 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 held steady at 4 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.2% | 12.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.1% | 5.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.7% | 2.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 6.8% | 10.3% | 6.5% | typical |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 4.8% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 18.2% | 13.6% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 28.5% | 21.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 97.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.6% | 3.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 16.8% | 20.2% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 1.9% | 10.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.2% | 1.0% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 92.1% | 83.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.8% | 23.3% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 6.2% | 11.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.53 | 1.81 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.55 | 1.40 | 1.80 | better |
‡ 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.
65.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 445 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 61.3% 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 111 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 0.84 therapist hours per resident per day in 2026Q1 — more than 95% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 23% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 65.7%CMS range 61.1–69.5 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 8.7%CMS range 6.6–11.5 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 61.3% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 62.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 64.0% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 99.1% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | 93.9% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.5%CMS range 5.1–10.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.27 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 116 beds and averages 99.9 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 3.99 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.91 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.18 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 3.80 hrs/resident/day on weekends vs 4.06 on weekdays — 6% thinner on weekends. RN hours go from 0.99 to 0.73 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 48% is about the same as the national median of 45%.
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
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.
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.
29 citations, most serious first. The 12 most serious are shown; the remaining 17 are one tap away and print in full.
- Immediate jeopardy · Jcited before2025-03-27 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 interviews, record review, and policy review, the facility failed to ensure allegations of abuse were reported for one of three residents (Resident (R) 80) reviewed for abuse. The facility did not report to the State Agency alleged staff-to-resident abuse within the required time frame. Facility staff did not report R80's allegation of employee-to-resident abuse to the Administrator. This failure to report the allegation in a timely manner allowed the accused staff member to continue working in the facility with other residents. The Immediate Jeopardy began on 07/07/24, undetermined time between 12:00 PM and 3:00 PM. On 03/13/25 at 7:42 PM, the Administrator was notified of Immediate Jeopardy (IJ) Past Non-Compliance (PNC) in the area of Resident Abuse at F609. Prior to this survey, the facility identified the seriousness and immediacy of the deficient practice and implemented a Removal Plan on 07/11/24. A review of the facility ' s investigation revealed that the episode of failing to report abuse in a…
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.
- Actual harm · Gcited before2026-04-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 observation, interview, record review, and review of other documentation as indicated, it was determined that for three (R12, R63, and R76) out of three residents sampled for accidents, the facility failed to ensure that the residents received adequate assistance and supervision to prevent accidents to the extent possible. R12, a completely dependent resident, sustained a fall from the bed to the floor while a staff member was providing care and sustained a right ankle fracture. R63, a resident who required extensive assistance for transfers, sustained L2 and L3 fractures during a transfer from the shower bed to the bed and was sent emergently to the hospital. R76, a resident who was completely dependent on staff for transfers, sustained an injury to the top of his head during a transfer from a mechanical lift to his motorized wheelchair. R76 was sent emergently to the hospital and received three staples to his scalp. Findings include: Cross Refer F658 1. R12's clinical record revealed: 1/2/19 – R12 was admitted to the facility with the following diagnoses, including, but…
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.
- Potential for harm · D2026-04-27 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview it was determined that for one (R23) out of thirty-four residents sampled for resident rights the facility failed to ensure R23 was provided with a dignified dining experience during lunch. Findings include:R23's clinical record revealed:6/13/22 - R23 was admitted to the facility.4/22/26 12:39 PM - During an observation R23 was in bed, E27 (CNA) entered the resident's room with R23's lunch tray. E27 placed the lunch tray on the overbed table and then began assisting R23 to eat while standing. E27 remained standing during the time frame that R23 was being assisted with the lunch meal.4/22/26 1:00 PM - During an interview E27 reported [R23] needs assistance with eating. The surveyor asked E27 If you were in the dining room and assisting a resident with their meal would you be sitting or standing E27 stated, I would be sitting E27 then stated and confirmed, I was standing I know that I should have been sitting down, I'm sorry.4/22/6 1:12 PM - Findings were confirmed with E28 (RN).
- Potential for harm · D2026-04-27 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews it was determined for one (R23) out of thirty four residents sampled for accommodations the facility failed to ensure R23's call light was within reach. Findings include:R23's clinical record revealed:6/13/22 - R23 was admitted to the facility. 4/22/26 10:39 AM - During an observation R23 was sitting up in the wheelchair near the left side of the foot of the bed. The call light cord was wrapped around the left side enabler at the head of the bed with the call light dangling near the floor.4/22/26 11:52 AM - A second observation revealed R23 sitting up in the wheelchair in the same position and the call light was not within reach.4/22/26 11:57 AM - During an observation E27 (CNA) and another staff CNA entered R23's room with a Hoyer lift to transfer R23 back to the bed.4/22/26 12:06 PM - R23 was observed in bed the call light remained wrapped around the enabler and not within the resident's reach.4/22/26 12:28 PM - E27 was observed in R23's room at this time and then exited the room. Call light remained not within R23's reach.4/22/26 12:43 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.
- Potential for harm · D2026-04-27 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and other documentation as indicated, it was determined that one (R76) out of three residents sampled for choices, the facility failed to ensure that R76, a resident who was completely dependent on the staff for showers, received showers per his preference to maintain good grooming and hygiene. Findings include:R76's clinical records revealed:6/2/22 - R76 was admitted to the facility with diagnoses, including but not limited to, brain bleed, seizure disorder and craniotomy which resulted in left sided paralysis.6/13/22 - R76's activities of daily living care plan (revised 3/7/24) included, . [R76] has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] CVA [cardiovascular accident] with left sided hemi [paralysis.] The interventions included, [R76] prefers to have afternoon or evening showers, he is scheduled for hair care/nail care and shower/bed bath weekly on Tuesday and Friday 3-11 shift, notify nurse if [R76] refuses.3/3/26 - R76's quarterly MDS assessment documented a BIMS score of 15, indicating a…
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.
- Potential for harm · Dcited before2026-04-27 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 (R43) out of three residents reviewed for accident hazards, the facility failed to notify the provider when a new skin alteration was identified after an earlier incident where R43 spilled coffee. Findings include: R43's record revealed: 3/5/26 - R43 was admitted to the facility. 3/11/26 - The admission MDS documented that R43 required set-up assistance for eating. 3/30/26 8:30 AM - A nurse's note by E21 (RN/SD) documented, Resident placed his coffee on the bed railing after letting go of the cup it fell back onto his lap spilling onto his bilateral upper thighs. Resident was not wearing pants (sic) this nurse and CNA were about to assist resident with morning care. B/L [Bilateral] upper thighs nonblanchable redness all skin intact at this time. After morning care resident denied pain to the area . 3/30/26 1:47 PM - A nurse's note by E20 (Wound Care RN) documented, Evaluated skin to abdomen, thighs . No scalded skin present. PT [Patient] denies pain. 3/30/26 2:47 PM - A progress note by E19 (NP) documented under…
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.
- Potential for harm · D2026-04-27 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review and other facility documentation it was determined for one (R12) out of four residents sampled for falls the facility failed to ensure that an RN performed the initial post fall assessment and documentation after R12 slid off of the bed and was lowered to the floor on the 11 PM-7 AM shift. An RN post fall assessment was not performed until the 7 AM - 3PM shift. Findings include: Cross Refer F689R12's clinical record revealed:1/2/19 - R12 was admitted to the facility with the following diagnoses including but not limited to anoxic brain injury, abnormal posture, multiple contractures of the upper and lower limbs and idiopathic progressive neuropathy.12/3/25 1:00 AM - A facility reported incident to the division documented [R12] sustained fall 12/3/25 complaint of ankle pain later in day. Xray obtained, results unclear. Repeat film obtained on 12/5/25.12/3/25 8:34 AM - A review of R12's initial post fall assessment was performed by E15 (ADON) on the 7 AM - 3 PM shift. [R12's] clinical record lacked evidence of an initial RN assessment until the next…
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.
- Potential for harm · D2025-12-01 · tag F0576 — isolatedEnsure residents have reasonable access to and privacy in their use of communication methods.
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 (R1) out of five residents reviewed for communication, the facility failed to provide R1 with a fully functional phone in her room or a location outside her room where calls can be made without being overheard. Findings include:3/26/18 - R1 was admitted to the facility with diagnoses including but not limited to stroke.5/24/21 - A diagnosis of hallucinations was added to R1 diagnoses list in the EMR.8/30/22 - R1 was diagnosed with paranoid personality disorder.5/26/23 - A PASARR Level II documented R1, As of 1/24/23, you having ongoing false beliefs and routinely call government agencies sharing your false beliefs. You have paranoia, choose not to take your medication, and sometimes choose not to have your labs. You are hyper-verbal regarding your false beliefs and unable to be redirected. The PASARR Level II documented, At this time you meet PASARR inclusion criteria for Serious mental Illness with the diagnosis of Paranoid Delusional Disorder and Major Depressive disorder. You also have the diagnoses of Paranoid…
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.
- Potential for harm · D2025-12-01 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that for five (R1, R2, R3, R4, R5) out of five residents reviewed for care plans, the facility failed to have evidence that an attending physician participated in the IDT team care plan meeting. Findings include:1. Review of R1's clinical record revealed:3/26/18 - R1 was admitted to the facility.6/26/25 3:58 PM - R1's EMR documented in a Care Conference Note, . resident refused to be apart (sic) of it. Residents (sic) family was invited, but did not attend. IDT (Interdisciplinary team) members present include Nsg (nursing), UMs (unit managers), dietician, ST (speech therapy), OT (occupational therapy) and SSA (social services assistant). Activities director unable to attend but gave report to SSA. CNA (certified nursing assistant) also provided input for todays (sic) meeting.9/25/25 12:37 PM - R1's EMR documented in a Care Conference Note, . resident stated that she did not want to have a care plan meeting and she refused to participate. Residents family…
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.
- Potential for harm · D2025-12-01 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
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 one (R1) out of five residents reviewed for social services, the facility failed to provide medically-related social services to R1, a resident diagnosed with a paranoid personality disorder. Findings include:Cross refer F576, F657 example 1According to the CMS's RAI Version 3.0 Manual,Section C - Brief Interview for Mental Status (BIMS) revealed the following: . A resident's performance on cognitive tests can be compared over time.-An abrupt change in cognitive status may indicate delirium and may be the only indication of a potentially life-threatening illness.-If performance worsens, then an assessment for delirium and/or depression should be considered, as a decline in mental status may also be associated with a mood disorder.When cognitive impairment is incorrectly diagnosed or missed, appropriate communication, activities, and therapies may not be offered.Section E: Behavior.Hallucinations and delusions may-be distressing to…
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.
- Potential for harm · D2025-12-01 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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 record review and interview, it was determined that for one (R3) out of five residents reviewed resident records, the facility failed to accurately document in the EMR that R3 had a responsible party who makes medical decisions. Findings include:10/30/23 - R3 was admitted to the facility with diagnoses, including but not limited to, schizophrenia.7/28/25 - A quarterly MDS (Minimum Data Set) evaluation documented R3 as having a BIMS (Brief Interview for Mental Status) score of 9, which was reflective of a moderate cognitive impairment.10/7/25 - F3 (R3's niece/ emergency contact) signed consents for R3 to receive the COVID-19 and influenza vaccinations.11/25/25 1:15 PM - A review of R3's EMR revealed that R3 was listed as her own responsible party despite having a documented BIMS score of 9.12/1/25 11:45 AM - During an interview, E1 (NHA) stated that a BIMS score under 12 showed a questionable cognitive status and the facility then obtains a responsible person who is willing to be the decision maker who signs all consents. E1 stated that the resident continues to be included…
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.
- Potential for harm · F2025-03-27 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
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 policy review, the facility failed to follow Transmission Based Precautions, use proper hand hygiene, and change gloves during incontinent care. These breaches in infection control could cause a spread in disease and affect all the residents. Findings include: Review of the facility policy titled Infection Prevention and Control Program Policy, revised 04/14/21, provided by the facility revealed individuals with suspected or diagnosed communicable disease are placed on the appropriate precaution for that disease, as recommended by the Centers for Disease Control and Prevention (CDC) . Employees will follow hand hygiene practices consistent with standards of care . Review of facility provided poster titled, Stop: Enhanced Barrier Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following high-contact resident care activities: .changing linen .changing briefs or…
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.
Show the remaining 17 citations
- Potential for harm · E2025-03-27 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
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, record review, and policy review, the facility failed to inform seven of seven residents in the resident council about the facility's grievance policy, the grievance official responsible for overseeing the grievance process was with their contact information and resolve grievances for three (Residents (R)158, R34, and R59) of three residents reviewed for grievances. This failure could prevent residents from addressing concerns and seeking resolution, leading to frustration and potentially impacting their well-being. Findings include: Review of the facility policy titled, Grievances, review date 01/03/25, provided by the facility revealed All grievances reported by a resident, responsible party, resident representative or family member will be promptly investigated and resolved. Follow up will be reported to the resident and/or reporting party. The facility will post guidance on how to file a grievance or complaint in prominent locations throughout the facility. a. All grievance…
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.
- Potential for harm · E2025-03-27 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and interviews, the facility failed to ensure a medication error rate of less than five percent. During observation of medication pass, there were three errors observed out of 30 opportunities, resulting in a 10% error rate. This had the potential to place two residents (Residents (R) 36 and R93) at risk of not receiving the full benefit of their medication therapy. Findings include: 1.Review of R93's facility provided Order Summary Report revealed ritalin oral tablet 20 milligrams (mg) (Methylphenidate HCL), give one tablet by mouth (PO) two times (BID) a day for attention deficit disorder (ADD), starting 01/15/25. Review of R93's facility provided Order Summary Report revealed omeprazole oral capsule delayed release 40 mg, give one capsule PO one time a day for gastroesophageal reflux disease (GERD), starting 02/04/25. Review of facility provided Blister Package indicated omeprazole 40 mg capsule, one time a day for GERD .Take on empty stomach, before eating. Review of facility provided Blister Package indicated Methylphenidate 20 mg tablet…
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.
- Potential for harm · E2025-03-27 · tag F0814 — failed to dispose of garbage properly — patternDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure the outdoor garbage/dumpster area was maintained in a manner to prevent pests from accessing garbage. A large dumpster contained garbage; there was no lid, and the bags were observed with holes and food. Findings include: During an observation on 03/10/25 at 9:45 AM with the Dietary Manager (DM), there was garbage on the ground around the garbage compactor including cigarette buts, paper, and pieces of cardboard. The DM verified the presence of the garbage on the ground and stated maintenance was responsible for keeping the area cleaned up. In addition, there was an extra-large dumpster that did not have a lid, and it could not be closed. This dumpster contained a lot of garbage, including large plastic bags of waste from the kitchen. There were five bags visible that had rips or torn areas with garbage such as food scraps/containers visible. The DM stated the compactor was gone for a while due to being repaired and that was why the large dumpster was present. The compactor had been repaired and returned to 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.
- Potential for harm · Dcited before2025-03-27 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 review of facility documentation, staff interview, and resident interview, the facility failed to protect the resident's right to be free from abuse for three of three (Resident (R) 80, 359, 78) reviewed for abuse of 41 sampled residents. This failure to protect the residents increased the risk of further exposure to abuse. Findings include: Review of the facility's policy titled, Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime, dated 01/03/25, revealed, Policy It is the policy of Cadia Healthcare to protect residents and prevent occurrences of abuse, neglect, mistreatment, misappropriation of resident property, exploitation, and crime. Cadia Healthcare adopts this policy to standardize procedures for employee screening, employee training, prevention, identification, investigation, protection, and reporting of abuse, neglect, mistreatment, misappropriation of resident property, exploitation, and reasonable suspicions of crime. Purpose: To ensure that all…
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.
- Potential for harm · Dcited before2025-03-27 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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, record review, and policy review, the facility failed to ensure an injury of unknown origin was investigated for one out of 11 residents reviewed for abuse (Resident (R)2). R2's thumb was noted with a 1.5 centimeter (cm) by 1.5 cm purple area with swelling; once staff to resident abuse was ruled out as a potential cause, the facility failed to investigate further to determine how R2 sustained the injury. Findings include: Review of the facility's Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime policy dated 01/03/25 revealed, It is the policy of [facility name] to protect residents and prevent occurrences of abuse, neglect, mistreatment, misappropriation of resident property, exploitation, and crime . Injuries of unknown source are injuries where the source of the injury was not observed by any person; the source of the injury could not be explained by the resident; the injury is suspicious because of the extent of the injury or 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.
- Potential for harm · D2025-03-27 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
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 interviews, record review, and facility policy review, the facility failed to provide written notification of a facility-initiated transfer to the resident/responsible party (RP) for three (Resident (R)41, R30, and R258) of four residents reviewed for hospitalization. The failure had the potential to affect the residents and/or their representative concerning the resident's appeal rights. Findings include: Review of the facility's policy titled Resident and Ombudsman Notification of Transfer or Discharge, revised 11/28/27, provided by the facility, revealed It is the policy of [facility name] to provide residents/resident representatives and the ombudsman with a notice of transfer/discharge as required by Center for Medicare & Medicaid Services (CMS). CMS requires advance written notification of a resident transfer/ discharge and the reasons for the discharge. This policy did not address emergency transfers to the hospital. Review of the facility's Notice of Transfer/Discharge, undated, provided by 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.
- Potential for harm · D2025-03-27 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 facility policy review, the facility failed to ensure one of three residents (Resident (R) 30) reviewed for hospital transfers was given a written copy of a bed hold notice prior to or within 24-hours of emergency transfer to the hospital. This failure created the potential for residents and/or responsible parties not to have the information needed to safeguard their return to the facility. Findings include: Review of the facility's policy titled, Bed Holds, dated 01/03/25, revealed Policy: Bed Hod Policy. Purpose: It is the policy of Cadia to implement bed holds in accordance with federal and state law, which require two written notices of a facility's Bed Hold Policy be provided to a resident and his/her family member or legal representative as outlined below. Procedure: . 2. Second Written Notice: (a) If the resident leaves the facility for emergency treatment at a hospital, a copy of the facility's Bed Hold Policy will be included in the documentation accompanying 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.
- Potential for harm · D2025-03-27 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to ensure that physician's orders were followed for one resident (Resident (R) 208) from a sample of 41 residents reviewed. This failure has the potential to negatively impact R208 and others that have similar orders that currently reside at the facility. Findings include: Review of R208's admission Record, located under the Profile in the Electronic medical record (EMR), indicated, that R208 was re-admitted to the facility on [DATE] for hypertension. Review of R208's Order Summary Report, dated 03/22/24, located under the Orders in the EMR, indicated Propranolol HCl Oral Tablet 40 milligrams (mg), give one tablet by mouth (PO) two times (BID) a day for hypertension, hold for heart rate (HR) less than 50. Review of Medication Administration Record (MAR), dated 03/01/24-03/30/24, under the tab Orders located in the EMR, indicated, .Propranolol HCL oral tablet 40 mg, give one tablet PO BID .hold for HR less than 50, starting 03/22/24. There is no…
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.
- Potential for harm · Dcited before2025-03-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 observations, interviews, and record review, the facility failed to ensure that fall interventions were followed for one resident (Resident (R) 82) out of five residents reviewed for falls, out of a sample of 41 residents. This failure had the potential to negatively impact R82 and other residents residing in the facility by not ensuring that staff consistently implemented fall interventions. Findings include: Review of R82's admission Record, located under the Profile tab in the Electronic Medical Record (EMR), indicated, that R82 was re-admitted to the facility on [DATE] was a diagnosis of fracture of the right pelvis and the right shoulder. Review of a significant change in status Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD), of 01/27/25, located under the MDS tab in the EMR, indicated, R82 had a Brief Interview for Mental Status (BIMS) of nine out 15, making R82 moderately impaired cognitively. Review of facility provided [name of state] Health and Social Services…
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.
- Potential for harm · D2025-03-27 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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, interviews, record review, and policy review, the facility failed to ensure that a resident with a urinary catheter bag was properly positioned in a manner to prevent potential urinary tract infections due to contamination for one of six residents (Resident (R)99) reviewed for urinary catheters and urinary tract infections out of a total sample of 41 residents. Findings include: Review of the facility's policy titled, Indwelling Urinary Catheter Management, revised 01/03/25, revealed It is the policy of [facility name] that residents with indwelling catheters are assessed for appropriate catheter use and that the resident's medical record reflects the supporting diagnosis .The medical record of residents admitted with an indwelling catheter is reviewed to determine the diagnosis and necessity of continued catheter use .The care plan is updated to reflect the resident's toileting needs .Residents with an indwelling catheter will receive daily/prn [as needed] catheter care. Catheters 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.
- Potential for harm · Dcited before2024-03-07 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 interviews, medical record review, and policy review, the facility failed to ensure the responsible party (RP) for one of three residents (Resident(R)214) sampled for pressure ulcers, were made aware of the resident's change in condition. Findings include: Review of the facility's policy titled Provider Notification of Resident Change in Medical Condition dated 01/03/24, documented staff will notify the provider and applicable POA (power of attorney)/responsible parties of accident with injury, abnormal and critical diagnostic testing results, significant change in condition in physical, mental, or psychosocial status in either life-threatening or clinical components. Review of R214's undated admission Record located in the electronic medical record (EMR), under the Profile tab, indicated R214 was admitted on [DATE], and discharged on 10/26/23. R214's diagnoses included Parkinson's disease without dyskinesia, without mention of fluctuations, dementia, abnormal posture, muscle weakness, and acute…
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.
- Potential for harm · D2024-03-07 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
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, review of housekeeping procedures, and record review, the facility failed to ensure one (Resident (R)1) room out of 33 rooms observed was properly cleaned to ensure a homelike environment. Findings include: Review of R1's Profile in the electronic medical record (EMR) under the Clinical tab revealed R1 was admitted on [DATE] and had diagnoses that included acute and chronic respiratory failure with hypoxia, acute and chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease (COPD), and chronic diastolic heart failure. Review of R1's Quarterly Minimum Data Set (MDS) in the EMR under the MDS tab with an Assessment Reference Date (ARD) dated 02/19/24 revealed a Brief Interview for Mental Status (BIMS) with a score of 15 out of 15 indicating R1 was cognitively intact. During an observation and interview with R1 on 03/04/23 at 1:18 PM in the resident's room revealed the floor around R1's bed was observed with dirt and debris, the bed frame had a heavy buildup…
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.
- Potential for harm · Dcited before2024-03-07 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 facility policy review, record review, resident and staff interviews, the facility failed to ensure two Residents of six residents (Resident (R) 62 and R86) reviewed for abuse remained free from physical abuse. A total of 33 residents were reviewed in the sample. Findings include: Review of the facility's Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime Policy most recently reviewed 01/03/24 read, in pertinent part, It is the policy of Cadia Healthcare to protect residents and prevent occurrences of abuse, neglect, mistreatment, misappropriation of resident property, exploitation, and crime. 1.Review of R86's admission Record, found in the electronic medical record (EMR) under the Profile tab, indicated the resident was admitted on [DATE] with diagnoses including dementia with mood and behavior disturbance. Review of R86's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/09/24, revealed a Brief Interview for Mental Status…
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.
- Potential for harm · Dcited before2024-03-07 · tag F0609 — failed to report abuse allegations — isolatedTimely 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, record review, document review, and facility policy review, the facility failed to ensure that an allegation of staff to resident abuse was reported timely to the State Agency for one of six residents (Resident(R)62) sampled for allegations of abuse. This had the potential to place the resident at risk for further abuse. Findings include: Review of the facility's policy titled Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime review date 01/03/24, documented Reporting and Response: Witnessed or suspected incidents of abuse or reasonable suspicions of crime are to be reported immediately. A witness who fails to report abuse, neglect, mistreatment, misappropriation of resident property, exploitation, or suspicions of crime is considered to be as culpable as the accused. Their name will also be reported to the appropriate regulatory agency and/or law enforcement for further investigation. The Director of Nursing (DON) or designee is responsible for conducting the abuse investigation. The Nursing Home Administrator (NHA)…
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.
- Potential for harm · Dcited before2024-03-07 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 facility policy review, record review, and resident and staff interviews, the facility failed to ensure a thorough investigation was completed related to allegations of potential abuse for two Residents of six residents (Resident (R)59 and R62) reviewed for abuse. A total of 33 residents were reviewed in the sample. Findings include: Review of the Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime Policy most recently reviewed 01/03/24 read, in pertinent part, It is the policy of Cadia Healthcare to protect residents and prevent occurrences of abuse, neglect, mistreatment, misappropriation of resident property, exploitation, and crime; and Investigation: The NHA (Nursing Home Administrator) or designee shall investigate allegations and report to appropriate regulatory agencies and/or law enforcement. All persons identified as involved in or with knowledge of the occurrence will be interviewed. 1.Review of R59's admission Record, found in the electronic…
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.
- Potential for harm · Dcited before2024-03-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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, interview, record review, and review of facility policy, the facility failed to complete a smoking assessment and secure smoking materials for one (Resident (R)61) out of one resident who the facility identified as a smokier out of a sample of 33 residents. This had the potential for an accident/hazard related to smoking. Findings include: Review of the facility's Smoking Policy, located in the admission Packet, dated 08/21, revealed Smoking and/or the use of tobacco, tobacco products or electronic cigarettes by residents or visitors is not permitted anywhere on facility property at any time. The definition of facility property for the purpose of this policy includes all land, buildings, structures, parking lots, sidewalks, and any vehicles owned or leased to the facility. Failure to maintain a smoke-free campus by residents and/or visitors could result in outcomes up to and including discharge. During the entrance conference on 03/04/24 the Administrator identified that the facility was a…
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.
- Potential for harm · D2024-03-07 · tag F0847 — isolatedInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review the facility failed to allow 30 days for a resident or their responsible party to rescind the voluntary Attachment #3: Binding Arbitration Agreement after it was signed. This failure would take the right to rescind the agreement away. Findings include: Review of the facility Attachment #3: Binding Arbitration Agreement revealed it stated . (3) this Agreement may be rescinded by written notice sent to the other party via Certified Mail, return receipt requested, within twenty-one (21) days of the date upon which it is signed. Interview with the admission Coordinator on 03/07/24 at 10:33 AM confirmed the form allowed for only 21 days to rescind the Arbitration Agreement. She stated no one has pursued arbitration.
“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.
- 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.
Fines & penalties
$10,608 in federal fines across 1 penalty.
- $10,608 — penalty dated 2025-03-27
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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 3.2 | +1.8 vs chain |
| Health inspection | 3 of 5 | 2.6 | +0.4 vs chain |
| Staffing | 5 of 5 | 3.8 | +1.2 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 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 / manager | Type | Role | Since |
|---|---|---|---|
| SCHAFER, RON | Individual | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 07/18/2011 |
| SILVER, STEPHEN | Individual | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 07/18/2011 |
| LITWA, KAREN | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 11/01/2012 |
| LONG TERM CARE CORP | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/23/2025 |
| ONIX GROUP LL | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/23/2025 |
| DITTMAR, LAURA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2020 |
| PRICE, ELIZABETH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2023 |
CMS files one row per role, so the 14 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
2 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.
This home reported $1.5M 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
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
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.
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 085056. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-27, 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.