13 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Wilmington, DE
3-star overall rating with 3-star inspections with $78,351 in total fines with 11 recent health deficiencies
3540 Three Little Bakers Blvd, Wilmington, DE
(302) 455-0808
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
177
Certified beds
Average residents
143
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cadia Healthcare
Operator or chain grouping
Approved since
2009-11-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 3 overall / 2 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.61
Registered nurse staffing · state 1.03 · national 0.68
LPN hours / resident day
1.53
Licensed practical nurse staffing · state 1.01 · national 0.87
Aide hours / resident day
2.40
Nurse aide staffing · state 2.47 · national 2.35
Total nurse hours
4.55
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.15
RN + LPN hours · state 2.04 · national 1.54
Weekend hours
3.97
Weekend nurse staffing · state 4.04 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.72 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.15 · national 0.07
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
3.17
CMS adjusted total nurse staffing hours
Case-mix index
1.97
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Program rank
12,098
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.89
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
4.46
Baseline 19.61% · Performance 19.36% · Measure score 4.46 · Achievement 4.46 · Improvement 0.46
Healthcare-associated infections
0
Baseline 8.58% · Performance 8.83% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0.92
Baseline 48.51% · Performance 59.91% · Measure score 0.92 · Achievement 0.92 · Improvement 0
Adjusted total nurse staffing
0.17
Baseline 2.71 hours · Performance 2.92 hours · Measure score 0.17 · Achievement 0 · Improvement 0.17
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 767 · Observed rate 10.56% · Lower 95% interval 8.97% |
| Discharge to community | 67.5% |
50.57%
16.9 pts better
|
Better than the National Rate · Eligible stays 861 · Observed rate 59.23% · Lower 95% interval 63.62% |
| Medicare spending per beneficiary | 1.29 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 517 · Denominator 517 |
| Falls with major injury | 0.97% |
0.77%
0.2 pts worse
|
Numerator 5 · Denominator 517 |
| Discharge self-care score | 79.2% |
53.69%
25.5 pts better
|
Numerator 179 · Denominator 226 |
| Discharge mobility score | 77.88% |
50.94%
26.9 pts better
|
Numerator 176 · Denominator 226 |
| Pressure ulcers or injuries, new or worsened | 0.77% |
2.29%
1.5 pts better
|
Numerator 4 · Denominator 517 · Adjusted rate 0.83% |
| Healthcare-associated infections requiring hospitalization | 8.83% |
7.12%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 562 · Observed rate 9.79% · Lower 95% interval 6.97% |
| Staff COVID-19 vaccination coverage | 3.77% |
8.2%
4.4 pts worse
|
Numerator 10 · Denominator 265 |
| Staff flu vaccination coverage | 63.55% |
42%
21.5 pts better
|
Numerator 197 · Denominator 310 |
| Discharge function score | 77.88% |
56.45%
21.4 pts better
|
Numerator 176 · Denominator 226 |
| Transfer of health information to provider | 99.77% |
95.95%
3.8 pts better
|
Numerator 434 · Denominator 435 |
| Transfer of health information to patient | 96.55% |
96.28%
0.3 pts better
|
Numerator 28 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 32.83% |
25.2%
7.6 pts better
|
Numerator 87 · Denominator 265 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.8
0.2 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.9 · Expected 3.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.4
0.5 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.3 · Expected 2.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.7%
4.3 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.5% |
97.4%
0.1 pts better
|
95.5%
2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
3.2%
1.7 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.0% · Q3 1.0% · Q4 1.9% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.5% |
6.5%
3 pts better
|
11.4%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 6.2% · Q4 6.7% · 4Q avg 3.5% |
| Percentage of long-stay residents who lose too much weight | 2.0% |
5.6%
3.6 pts better
|
5.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 1.0% · Q4 5.0% · 4Q avg 2.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.8% |
21.1%
11.7 pts worse
|
19.6%
13.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.3% · Q2 33.3% · Q3 32.0% · Q4 33.3% · 4Q avg 32.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.4% |
12.0%
8.6 pts better
|
16.7%
13.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 2.8% · Q3 1.3% · Q4 5.3% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.9% |
17.5%
9.6 pts better
|
16.3%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 13.5% · Q3 4.3% · Q4 9.1% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.3% |
14.7%
8.4 pts better
|
14.9%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 1.8% · Q3 11.1% · Q4 7.4% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.7%
About the same
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.7% · Q3 0.8% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
2.0%
0.8 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.0% · Q3 0.0% · Q4 1.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.3% |
21.6%
15.3 pts better
|
19.8%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 7.2% · Q3 4.4% · Q4 6.1% · 4Q avg 6.3% |
| Percentage of long-stay residents with pressure ulcers | 8.0% |
4.4%
3.6 pts worse
|
5.1%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 9.5% · Q3 7.2% · Q4 6.7% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
83.5%
14.4 pts better
|
81.7%
16.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.3% · Q2 98.7% · Q3 97.5% · Q4 98.4% · 4Q avg 97.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.2% |
11.2%
4 pts better
|
12.0%
4.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.2% · Observed 7.3% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
0.9%
0.5 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.9% · Q3 0.5% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.2% |
83.1%
9.1 pts better
|
79.7%
12.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.5% |
21.5%
2 pts better
|
23.9%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.5% · Observed 22.2% · Expected 27.1% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Quality of Life and Care (9 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-02
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-21
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2025-06-02
Health
Honor 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.
Corrected 2025-04-18
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-02
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-02
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-07
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-07
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-04-07
Health
Honor 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.
Corrected 2024-05-12
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-05-12
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-05-12
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-05-12
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-05-12
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-05-12
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-05-12
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2023-04-19
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-09-08
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-11-15
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-15
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-15
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-11-15
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-24
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-03-24
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-03-24
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-03-24
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-03-24
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-03-24
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-03-24
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-03-24
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-11-11
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-11-11
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2019-11-11
Health
Provide and implement an infection prevention and control program.
Corrected 2019-11-11
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-11-11
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-11-11
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-11-11
Health
Ensure that residents are free from significant medication errors.
Corrected 2019-11-11
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-11-11
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2019-11-11
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-11-11
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-11-11
Health
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.
Corrected 2019-11-11
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-11-11
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2019-11-11
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-11-11
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2019-11-11
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2019-11-11
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2019-11-11
Health
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Corrected 2019-11-11
Health
Provide or obtain dental services for each resident.
Corrected 2019-11-11
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-11-11
Penalties and ownership
Fine · fine $52,305
Fine
Payment Denial · denial start 2025-05-28 · 5 days
5 day denial
Fine · fine $12,649
Fine
Fine · fine $13,397
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Contracted Managing Employee · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Contracted Managing Employee · Individual
Contracted Managing Employee · Individual
Contracted Managing Employee · Individual
Nearby options
Wilmington, DE
2-star overall rating with 1-star inspections with $99,184 in total fines with 29 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Wilmington, DE
1-star overall rating with 1-star inspections with Special Focus status with $484,596 in total fines with 30 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Newark, DE
3-star overall rating with 2-star inspections with $29,309 in total fines with 13 recent health deficiencies
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