Cadia Rehabilitation Renaissance
CADIA REHABILITATION RENAISSANCE in MILLSBORO, DE — inspection on August 25, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on record review and interview it was determined that for one (R123) out of four residents reviewed for abuse the facility failed to ensure an allegation of misappropriation of resident property was reported to the state agency within the required time frame.
Findings include: 1.
The facility policy on abuse last updated January 3, 2025, indicated, All alleged incidents involving misappropriation shall be reported to the NHA/designee immediately .Incidents involving reasonable suspicion of criminal conduct are reported to the applicable state agency within eight hours or withing two hours if the conduct causes serious bodily harm. 1.
Review of R123's clinical record revealed: 7/20/25 11:30 AM - A statement written by E12 (LPN) documented, At 10:45 AM I counted .however six [purple tablets] were missing. I recognized the discrepancy.
Nursing supervisor [E9 (RN)] was immediately made aware, and she immediately made E2 (former DON) aware. 8/7/25 - E2 (former DON) submitted an incident report to the state agency that alleged [R123] bought in home medications upon admission .six purple pills noted on count sheet. It was noted that the six purple pills were missing.
The incident report documented that the incident occurred on 7/19/25 nineteen days prior to the day the allegations were reported. 8/21/25 11:36 AM -
During an interview, E9 (RN supervisor) stated, On July 20th on a Sunday and [E12(LPN)] said the count was incorrect, she said the six purple pills weren't there. E9 then confirmed that she notified E2 (DON) and that E2 was the person responsible for reporting. 8/21/25 11:45 AM -
During an interview, E2 (former DON) confirmed recognizing the incident as an allegation of misappropriation of resident property and stated, I was delayed in reporting it because I was doing the investigation. 8/21/25 12:59 PM -
During an interview, E1 (NHA) confirmed the delayed reporting. 8/25/25 2:10 PM - Findings were reviewed with E1 (NHA), E10 (CO), and E11 (CNO) during the exit conference.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/25/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Cadia Rehabilitation Renaissance
26002 John J Williams Highway Millsboro, DE 19966
SUMMARY STATEMENT OF DEFICIENCIES
Based on record review and interview it was determined that the facility failed to ensure accuracy of the medication reconciliation documentation for a controlled drug.
Findings include: 8/3/25 - A controlled drug administration record for R123 documented that the facility received thirty morphine capsules from the pharmacy. 8/5/25 - The controlled drug administration record for R123's morphine revealed that E12 (LPN) administered one of the capsules to R123 and documented that twenty-nine capsules remained. 8/6/25 The controlled drug administration record for R123's morphine indicated that E12 (LPN) witnessed E13 (RN) destroy a remaining amount of twenty-four of R123's morphine capsules.
The controlled drug administration record had previously documented a remaining amount of twenty-nine capsules, a five-capsule deficit.
The clinical record and drug administration record lacked clarification to account for the five-capsule deficit. 8/20/25 1:38 PM -
During an interview, E11 (CNO) stated that the facility had not identified any medication reconciliation discrepancies regarding medications received from the pharmacy for R123. 8/20/25 1:45 PM -
During an interview, E12 (LPN) denied knowledge of the five capsule deficit documented on the controlled drug medication administration record for R123's morphine capsules.
When shown the record, E12 confirmed witnessing the destruction of the medications, and stated I don't remember there being an error. 8/20/25 1:53 PM -
During an interview, E13 (RN) confirmed his signature on the controlled drug medication administration record for R123's morphine capsules. E13 confirmed the five capsule discrepancy and stated, I think it's just a typo. 8/20/25 2:26 PM -
During an interview E11 (CNO) confirmed the discrepancy on the controlled drug administration record for R123's morphine and stated, it was a clerical error. 8/25/25 2:10 PM - Findings were reviewed with E1 (NHA), E10 (COO) and E11 (CNO) during the exit conference.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/25/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Cadia Rehabilitation Renaissance
26002 John J Williams Highway Millsboro, DE 19966
SUMMARY STATEMENT OF DEFICIENCIES
8/20/25 2:26 PM -
During an interview, E11 (CNO) confirmed the facility accepted and stored unlabeled medications from R123. E11 stated, we can't assume what they [the medications] are but we can't get rid of them because they are the residents property. 8/21/25 11:32 AM -
During an interview, E25 (LPN) confirmed the facility received and stored six purple pills from R123. E25 stated, There were six purple pills mixed in with the bottle of oxycodone. We took them for safety; we counted the medications in front of [R123].
When asked how staff determined what the six purple pills were due to the bottle being unlabeled E25 stated, [R123] was cooperative and telling us what the medication was.
The facility accepted and stored unidentifiable/unlabeled medication as evidenced by the acceptance of six purple pills not in their original container received from R123. 2. 8/19/25 10:48 AM - During inspection of a [NAME] unit medication cart, one opened bottle of aspirin, and one opened bottle of Colace were observed without open dates. E21 (LPN) immediately confirmed the finding. 8/19/25 12:27 PM - During inspection of a [NAME] unit medication cart, one opened bottle of aspirin, and one open bottle of Tylenol were observed without open dates. E16 (LPN) immediately confirmed the finding. 8/19/25 3:03 PM - During inspection of a Rehoboth unit medication cart, an unused Humalog insulin pen was observed in a medication cart.
The pharmacy labeled the insulin pen with manufacturer's instructions that directed the insulin pen to be refrigerated until opened. E24 (RN) immediately confirmed the finding. 8/25/25 2:10 PM - Findings were reviewed with E1 (NHA), E10 (COO) and E11 (CNO) during the exit conference.
Facility ID: