Millsboro, DE

Cadia Rehabilitation Renaissance

2-star overall rating with 2-star inspections with $13,627 in total fines with 21 recent health deficiencies

26002 John J Williams Highway, Millsboro, DE

(302) 947-4200

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

130

Certified beds

Average residents

115

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Cadia Healthcare

Operator or chain grouping

Approved since

2008-01-29

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

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.72

Registered nurse staffing · state 1.03 · national 0.68

LPN hours / resident day

0.72

Licensed practical nurse staffing · state 1.01 · national 0.87

Aide hours / resident day

2.26

Nurse aide staffing · state 2.47 · national 2.35

Total nurse hours

3.70

All reported nurse hours · state 4.51 · national 3.89

Licensed hours

1.44

RN + LPN hours · state 2.04 · national 1.54

Weekend hours

3.44

Weekend nurse staffing · state 4.04 · national 3.43

Weekend RN hours

0.53

Weekend registered nurse coverage · state 0.72 · national 0.47

Physical therapist

0.08

Reported PT staffing · state 0.15 · national 0.07

Adjusted RN hours

0.77

CMS adjusted RN staffing hours

Adjusted total hours

3.96

CMS adjusted total nurse staffing hours

Case-mix index

1.28

Higher values indicate more complex resident acuity

RN turnover

54%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

55%

Annual nurse turnover · state 42% · national 46%

SNF VBP

Value-based purchasing

Program rank

13,032

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

8.90

Composite VBP score used to determine payment impact.

Payment multiplier

0.9808

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 17.57% · Performance 24.95% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

1.64

Baseline 4.94% · Performance 7.34% · Measure score 1.64 · Achievement 1.64 · Improvement 0

Total nurse turnover

Baseline 52.63% · Performance 67.97% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

1.92

Baseline 3.74 hours · Performance 3.62 hours · Measure score 1.92 · Achievement 1.92 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.85%	10.72% 0.1 pts worse	No Different than the National Rate · Eligible stays 365 · Observed rate 10.14% · Lower 95% interval 8.45%
Discharge to community	59.4%	50.57% 8.8 pts better	Better than the National Rate · Eligible stays 350 · Observed rate 54.86% · Lower 95% interval 53.45%
Medicare spending per beneficiary	1.21	1.02 0.2 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 277 · Denominator 277
Falls with major injury	0.36%	0.77% 0.4 pts better	Numerator 1 · Denominator 277
Discharge self-care score	56.88%	53.69% 3.2 pts better	Numerator 62 · Denominator 109
Discharge mobility score	50.46%	50.94% 0.5 pts worse	Numerator 55 · Denominator 109
Pressure ulcers or injuries, new or worsened	1.44%	2.29% 0.9 pts better	Numerator 4 · Denominator 277 · Adjusted rate 1.48%
Healthcare-associated infections requiring hospitalization	7.34%	7.12% 0.2 pts worse	No Different than the National Rate · Eligible stays 262 · Observed rate 7.25% · Lower 95% interval 5.06%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 168
Staff flu vaccination coverage	18.29%	42% 23.7 pts worse	Numerator 32 · Denominator 175
Discharge function score	50.46%	56.45% 6 pts worse	Numerator 55 · Denominator 109
Transfer of health information to provider	94.86%	95.95% 1.1 pts worse	Numerator 166 · Denominator 175
Transfer of health information to patient	98.51%	96.28% 2.2 pts better	Numerator 66 · Denominator 67
Resident COVID-19 vaccinations up to date	6.21%	25.2% 19 pts worse	Numerator 9 · Denominator 145

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.9	1.8 0.1 pts worse	1.9 About the same	Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.4 · Expected 1.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.6	1.4 1.2 pts worse	1.8 0.8 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.1 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.7%	95.7% 4 pts better	93.4% 6.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.9% · 4Q avg 99.7%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	97.8%	97.4% 0.4 pts better	95.5% 2.3 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 97.8%
Percentage of long-stay residents experiencing one or more falls with major injury	4.7%	3.2% 1.5 pts worse	3.3% 1.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 3.6% · Q3 5.7% · Q4 4.5% · 4Q avg 4.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	6.5% 6.5 pts better	11.4% 11.4 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 who lose too much weight	4.0%	5.6% 1.6 pts better	5.4% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 5.3% · Q3 3.6% · Q4 2.3% · 4Q avg 4.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	32.2%	21.1% 11.1 pts worse	19.6% 12.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 33.8% · Q2 28.8% · Q3 34.9% · Q4 31.4% · 4Q avg 32.2%
Percentage of long-stay residents who received an antipsychotic medication	13.9%	12.0% 1.9 pts worse	16.7% 2.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 14.9% · Q3 16.0% · Q4 8.3% · 4Q avg 13.9% · 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	15.1%	17.5% 2.4 pts better	16.3% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 33.0% · Q2 7.8% · Q3 12.0% · Q4 8.4% · 4Q avg 15.1% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	19.7%	14.7% 5 pts worse	14.9% 4.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.7% · Q2 16.4% · Q3 19.8% · Q4 17.1% · 4Q avg 19.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.9%	0.7% 0.2 pts worse	1.0% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 1.1% · Q4 1.1% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	2.0% 2 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	27.2%	21.6% 5.6 pts worse	19.8% 7.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 36.5% · Q2 25.0% · Q3 32.9% · Q4 14.6% · 4Q avg 27.2%
Percentage of long-stay residents with pressure ulcers	3.1%	4.4% 1.3 pts better	5.1% 2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 5.5% · Q3 2.1% · Q4 2.2% · 4Q avg 3.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	95.9%	83.5% 12.4 pts better	81.7% 14.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 96.0% · Q2 94.6% · Q3 94.9% · Q4 98.2% · 4Q avg 95.9%
Percentage of short-stay residents who had an outpatient emergency department visit	18.6%	11.2% 7.4 pts worse	12.0% 6.6 pts worse	Short Stay · 20240701-20250630 · Adjusted 18.6% · Observed 18.3% · Expected 10.9% · 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 0.0% · Q3 0.8% · Q4 0.9% · 4Q avg 0.4% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	82.1%	83.1% 1 pts worse	79.7% 2.4 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 82.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	26.4%	21.5% 4.9 pts worse	23.9% 2.5 pts worse	Short Stay · 20240701-20250630 · Adjusted 26.4% · Observed 27.4% · Expected 24.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-09-19 · Fire 2024-09-19

21 health deficiencies

Top issue: Pharmacy Service (5 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2023-08-07 · Fire 2023-08-07

9 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2021-10-22 · Fire 2021-10-22

21 health deficiencies

Top issue: Resident Rights (7 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-08-25

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-10-09

D · Potential for more than minimal harm 2025-08-25

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2025-10-09

D · Potential for more than minimal harm 2025-08-25

F761 · Pharmacy Service Deficiencies

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 2025-10-09

D · Potential for more than minimal harm 2025-06-02

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-06-27

D · Potential for more than minimal harm 2025-06-02

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-06-27

E · Potential for more than minimal harm 2024-09-19

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-10-23

E · Potential for more than minimal harm 2024-09-19

F847 · Administration Deficiencies

Health

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Corrected 2024-10-23

E · Potential for more than minimal harm 2024-09-19

F848 · Administration Deficiencies

Health

Provide a neutral and fair arbitration process and agree to arbitrator and venue.

Corrected 2024-10-23

E · Potential for more than minimal harm 2024-09-19

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-19

F561 · Resident Rights Deficiencies

Health

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-19

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-19

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-19

F657 · Resident Assessment and Care Planning Deficiencies

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 2024-10-23

D · Potential for more than minimal harm 2024-09-19

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-19

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-19

F700 · Quality of Life and Care Deficiencies

Health

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-19

F742 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-19

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-19

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-19

F761 · Pharmacy Service Deficiencies

Health

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-19

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2024-10-23

J · Immediate jeopardy 2024-06-26

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-06-14

D · Potential for more than minimal harm 2024-05-02

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-06-15

D · Potential for more than minimal harm 2024-05-02

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-06-15

E · Potential for more than minimal harm 2023-08-07

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2023-09-08

D · Potential for more than minimal harm 2023-08-07

F585 · Resident Rights Deficiencies

Health

Honor 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.

Corrected 2023-09-08

D · Potential for more than minimal harm 2023-08-07

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2023-09-08

D · Potential for more than minimal harm 2023-08-07

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-09-08

D · Potential for more than minimal harm 2023-08-07

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-09-08

D · Potential for more than minimal harm 2023-08-07

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2023-09-08

C · Minimal harm 2023-08-07

F577 · Resident Rights Deficiencies

Health

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Corrected 2023-09-08

E · Potential for more than minimal harm 2021-10-22

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2021-11-12

E · Potential for more than minimal harm 2021-10-22

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2021-11-12

E · Potential for more than minimal harm 2021-10-22

F657 · Resident Assessment and Care Planning Deficiencies

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 2021-11-12

E · Potential for more than minimal harm 2021-10-22

F761 · Pharmacy Service Deficiencies

Health

Corrected 2021-11-12

E · Potential for more than minimal harm 2021-10-22

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2021-11-12

E · Potential for more than minimal harm 2021-10-22

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2021-11-12

E · Potential for more than minimal harm 2021-10-22