Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cadia Rehabilitation Capitol during CMS and state inspections, most recent first.
A resident with dementia and impaired cognition, who had an order for 0.25 mL (5 mg) concentrated morphine sulfate solution PRN for pain and a separate order for 15 mg MS Contin tablets, received a massive overdose when an LPN misinterpreted 15 mg as 15 mL and administered 15 mL of the liquid morphine instead of 0.25 mL. The LPN reported relying on the MAR display of 15 mg and, after asking a supervisor a general question about narcotic administration, proceeded to give the incorrect volume. The error was recognized at shift change, and documentation by nursing and the medical director confirmed that the resident received 300 mg instead of 5 mg, requiring two doses of naloxone to reverse the overdose and leading surveyors to cite an immediate jeopardy deficiency for a significant medication error.
Two residents reported that CNAs were rough during care and, in one case, that clothing was torn. In both situations, staff received the abuse allegations but did not ensure they were reported to the state agency within the facility’s required two-hour timeframe. Leadership later confirmed awareness of the policy requirement and acknowledged that the reporting timeframes were not met.
Failure to Update PASRR After Mental Health Change: A resident with a prior PASRR Level II outcome and multiple psychiatric diagnoses developed new and ongoing mental health conditions, including bipolar disorder, adjustment disorder with mixed anxiety and depressed mood, and unspecified dementia with other behavioral disturbance. MDS assessments documented these changes, but the NHA confirmed the PASRR evaluation was not updated and submitted to the state authority when the new diagnoses were identified.
A resident with acute respiratory failure and interstitial pulmonary disease had BiPap ordered at HS and PRN, but the mask and tubing were observed lying on the bedside table and floor instead of being stored in a protective plastic bag when not in use. An LPN stated that BiPap equipment is required to be stored in a protective plastic bag and then placed the equipment into one after confirming it was not stored properly.
A resident with dementia, anxiety, depression, and a bee venom allergy had repeated pharmacist MRR recommendations for an EpiPen and concerns about Risperdal use, and the physician marked the recommendations as agreed. However, the resident still had no EpiPen order, and Risperdal continued for mood; staff confirmed the missing EpiPen and that the diagnosis for the Risperdal order was not correct.
A resident’s record was incomplete for beneficiary notification because the facility could not locate the signature page for the NOMNC. The NOMNC had been issued to the resident to notify that services would end, but the worksheet and related documents lacked the second page needed to verify receipt and understanding. The SW confirmed the missing signature page during interview.
The facility failed to ensure food safety by not requiring dietary aides with beards to wear beard nets during food preparation, risking contamination for 109 residents. Additionally, expired and undated food items were found in the main refrigerator and freezer, indicating lapses in food storage protocols.
A resident with moderate cognitive impairment and limited use of one hand was repeatedly found without access to their call light, as it was placed under the bed. Staff interviews confirmed awareness of the need for accessibility, but the facility lacked a specific policy on call lights.
Two incidents of resident-to-resident abuse occurred in the facility, involving residents with cognitive impairments and aggressive behaviors. In one case, a resident struck another after a hallway incident, and in another, a resident slapped another during a dinner dispute. Both incidents were confirmed as abuse by the DON, indicating a failure to implement the facility's abuse prevention policy effectively.
An LTC facility failed to report a resident-to-resident abuse incident to the State Agency within the required two-hour timeframe. A resident with severe cognitive impairment urinated on the floor, prompting another cognitively impaired resident to yell and strike him. The DON learned of the incident later and reported it, but the nurse on duty did not follow the reporting protocol.
A facility failed to thoroughly investigate an abuse allegation involving a resident who reported rough treatment by a CNA. The investigation only included an interview with one female resident, neglecting to interview other male residents who received care from the same CNA, contrary to the facility's policy.
A resident with hemiplegia and hemiparesis was found with a mattress that did not fit the bed frame, creating a gap between the mattress and footboard. This gap, observed to be up to 11 inches, posed a risk of entanglement for the resident's feet. The facility did not provide a policy on mattress fitting by the survey exit.
A resident with severe cognitive impairment and multiple health conditions was found without a functioning call light or alternative device due to a malfunction in the facility's call light system. Despite other residents receiving doorbell-like devices, this resident had no means to call for assistance, relying solely on their voice. The facility's staff were aware of the issue, but the resident's room remained without a functioning call system due to wiring problems.
Significant Morphine Dosing Error Due to Misinterpretation of mg and mL
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when an incorrect dose of concentrated morphine sulfate oral solution was administered. The resident had dementia and a quarterly MDS showing moderately impaired cognition with a BIMS score of 10 and was receiving opioids for pain. The physician’s order in place directed that the resident receive 0.25 mL (5 mg) of morphine sulfate concentrate oral solution every three hours as needed for pain, and on a later date a new order was entered for MS Contin (morphine sulfate) 15 mg extended-release tablets by mouth twice daily for pain. On the morning of the incident, the assigned LPN administered 15 mL of the concentrated morphine sulfate solution instead of the ordered 0.25 mL dose. In a written statement, the LPN reported that the electronic system displayed an ordered dose of morphine 15 mg, while the bottle label stated 0.25 mL, and that after seeking clarification from a supervisor, she was told to follow the dose listed in the MAR. The LPN then incorrectly interpreted 15 mg as 15 mL and administered that amount. Another nurse later confirmed that she had previously worked with the resident, was familiar with the correct 0.25 mL PRN dose, and had left 17.25 mL of morphine sulfate concentrate in the bottle at the end of her prior shift, while the LPN reported having given 15 mL to the resident. The error was discovered during shift exchange when the outgoing nurse recognized the discrepancy between milligrams and milliliters. Nursing notes documented that the resident had received 15 mL of liquid morphine, and the medical director’s note confirmed that, given the concentration of 20 mg/mL, the resident received 300 mg instead of the prescribed 5 mg. The facility determined that the nurse failed to perform the rights of medication administration when she misinterpreted 15 mg as 15 mL, resulting in the resident receiving 59 times the ordered dose of morphine sulfate solution. The resident required administration of naloxone intramuscularly on two occasions to reverse the overdosage, and the situation was identified by surveyors as immediate jeopardy, past non-compliance.
Removal Plan
- Upon discovery of the medication error, R5 was immediately assessed and the physician was notified; a new order for Narcan (Naloxone) was obtained and administered; R5's responsible party and Hospice were notified; R5 was placed on alert charting to monitor vital signs and respiratory status.
- An audit was completed on residents with orders for liquid morphine and no other errors were identified.
- An audit of residents receiving controlled substances was completed to determine if any other residents had orders for the same medication in two different forms and no other residents were identified.
- The facility conducted a root cause analysis.
- Education with licensed nurses was completed on the five rights of medication administration.
- The medication error was reviewed with the medical director at an ad hoc QAPI meeting.
- The Director of Nursing will conduct audits of liquid morphine medication administration weekly until 100% compliance is achieved for 3 consecutive weeks, then monthly until 100% compliance is achieved for 3 consecutive months; all audits will be reviewed by the QAPI Committee.
Failure to Timely Report Allegations of Abuse to State Agency
Penalty
Summary
The facility failed to timely report allegations of abuse to the state agency for two residents. For one resident, a CNA documented in a written statement on 10/26/25 that on the previous night at approximately 11:15 PM, the resident reported that a CNA had torn her clothes and was rough with her. The CNA confirmed in an interview that this allegation was reported to a nurse on 10/25/25. However, the facility did not submit the allegation of staff-to-resident abuse to the state agency until 11:08 AM on 10/26/25, which was more than two hours after the resident’s initial report to facility staff. The ADON later stated that leadership only became aware of the incident by reading notes and that no one had made leadership aware at the time of the allegation. For another resident, the clinical record showed that the resident reported on 10/25/25 at 7:15 PM that a CNA was rough while providing care. The facility did not report this allegation of abuse to the state agency until 11:09 AM on 10/27/25, which exceeded the required two-hour reporting timeframe. In interviews, both the DON and the NHA confirmed that allegations of abuse must be reported within two hours and acknowledged that the alleged abuse was not reported within that timeframe. The facility’s abuse policy, last updated on 1/9/26, specified that allegations of abuse must be reported to the appropriate state regulatory authority within two hours, and the survey findings were reviewed with facility leadership during the exit conference.
Failure to Update PASRR After Significant Mental Health Change
Penalty
Summary
The facility failed to coordinate assessments with the PASRR program and failed to refer a resident for a PASRR evaluation after a significant change in mental health status. Record review showed that R5 was re-admitted to the facility on 2/6/23 and had a prior PASRR Level II outcome dated 11/13/23 listing multiple mental health diagnoses, including adjustment disorder with depressed mood, delusional disorder, dementia, mood disorder NOS, anxiety disorder NOS, psychotic disorder NOS, insomnia, and major depressive disorder, recurrent, severe, with psychotic symptoms. Subsequent MDS assessments documented new and ongoing psychiatric and mood disorder diagnoses for R5, including bipolar disorder, adjustment disorder with mixed anxiety and depressed mood, unspecified mood affective disorder, restlessness and agitation, and unspecified dementia with other behavioral disturbance. The record also showed new diagnosis onset dates in 2024 for adjustment disorder with mixed anxiety and depressed mood, bipolar disorder, and unspecified dementia with other behavioral disturbance. During interview, the NHA confirmed that R5's PASRR evaluation was not updated and submitted to the state authority when these diagnoses were identified in 2024.
BiPap Equipment Not Stored Properly
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for one resident by not ensuring the resident’s BiPap equipment was stored in a protective plastic bag when not in use. The resident was admitted with diagnoses of acute respiratory failure and interstitial pulmonary disease and was documented as cognitively intact on the quarterly MDS. A physician’s order directed BiPap use at bedtime and as needed, with settings of 10 cm H2O and oxygen bleed-in at 2 liters. However, the treatment administration record did not contain an order directing that the BiPap mask and tubing be stored in a protective plastic bag when not in use. During observations, the resident’s BiPap mask was seen lying on the bedside table with the tubing on the floor on two separate occasions. An LPN stated that BiPap masks and tubing are required to be stored in a protective plastic bag when not in use and then confirmed the equipment was not stored that way before placing it into a protective plastic bag.
Failure to Act on Pharmacist MRR Recommendations
Penalty
Summary
The facility failed to implement its monthly drug regimen review (MRR) process when pharmacist recommendations that were marked as agreed by the physician were not carried out for one resident. The resident was admitted with dementia with behavioral disturbance, anxiety, depression, and a bee venom allergy. The pharmacist’s MRRs repeatedly recommended that an EpiPen be considered because of the bee venom allergy, and also identified Risperdal as an inappropriate antipsychotic use when it was prescribed for major depressive disorder and later for mood. Despite the recommendations being marked as agreed by the physician, the resident’s physician orders still showed Risperdal continued as indicated for mood, and no EpiPen order was written. During record review and interviews, staff confirmed that the resident did not have an EpiPen in the medication cart. An LPN/UM also confirmed that the correct diagnosis was not listed for the Risperdal order and that no EpiPen had been ordered for the resident. The findings were reviewed with the NHA and DON during the exit conference.
Incomplete Beneficiary Notification Record
Penalty
Summary
The facility failed to maintain accurate and complete records for one resident, R119, in relation to beneficiary notification. Review of the medical record showed that on 7/25/25 the facility provided a Notice of Medicare Non-Coverage (NOMNC) to R119 stating that services would end that day. However, during the beneficiary notification review on 1/23/26, the resident’s worksheet and related documents did not include the second page of the NOMNC, which is the signature page used to verify that the resident or responsible party received and understood the notice. During an interview that same day, the SW confirmed that the facility was unable to locate R119’s signature page for the NOMNC.
Failure to Adhere to Food Safety Standards
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not ensuring that beard guards were worn during food production. Observations during multiple meal preparations revealed that two male dietary aides with beards did not wear beard nets while working at the food preparation station. This was confirmed during interviews with the Food Service Director and the dietary aides, who acknowledged the requirement to wear beard guards but admitted to forgetting to do so. This oversight had the potential for physical contamination of the food served to all 109 residents consuming meals from the kitchen. Additionally, the facility did not store food in accordance with professional standards for service safety. During an inspection of the main refrigerator and freezer, several food items were found to be expired or lacked current dates. Items such as potato salad, salad dressing, hard-boiled eggs, grape jelly, chicken salad, chicken cutlets, and hamburger patties were either undated or past their expiration dates. The Food Service Director noted that the weekend kitchen staff were responsible for checking and discarding out-of-date food items, indicating a lapse in the facility's food safety protocols.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to ensure that a resident had access to their call light, which is essential for meeting their needs. The resident, who was moderately cognitively impaired with a BIMS score of 12 out of 15, was observed multiple times with the call light underneath the bed, making it inaccessible. The resident, admitted with conditions such as adjustment disorder with depressed mood, congestive heart disease, chronic kidney disease stage three, and gout, was unable to locate the call light and expressed that he did not know where it was. This situation was observed on several occasions, indicating a consistent issue with the call light's accessibility. Interviews with staff, including an LPN and a CNA, revealed that the staff were aware that the call light should be within reach of the resident's right hand, as the resident could not use his left hand. However, the call light was repeatedly found under the bed, and the staff admitted to not realizing its inaccessibility. The Director of Nurses confirmed that CNAs were responsible for ensuring call lights were accessible, but the facility lacked a specific policy on call lights, as stated by the Nurse Consultant.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by two incidents of resident-to-resident abuse. In the first incident, a resident with severe cognitive impairment and a history of aggressive behavior struck another resident in the back after the latter began urinating on the floor. Both residents were known to exhibit aggressive behaviors, and the incident was confirmed as abuse by the Director of Nursing (DON). The facility's abuse policy, which aims to protect residents and prevent abuse, was not effectively implemented in this case. In the second incident, a resident with moderate cognitive impairment and a history of verbal aggression slapped another resident during a dispute over a chair at dinner. The resident who was slapped did not sustain any visible injuries and denied provoking the other resident. The DON also confirmed this incident as resident-to-resident abuse. Both incidents highlight the facility's failure to ensure a safe environment for residents, as required by their abuse prevention policy.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an incident of resident-to-resident abuse to the State Agency within the required two-hour timeframe. The incident involved a resident with severe cognitive impairment, who was ambulating in the hallway and began to urinate on the floor. Another resident, also severely cognitively impaired, yelled at the first resident and then struck him in the back. This incident was documented in the facility's incident report. The Director of Nursing (DON) became aware of the incident while reviewing notes from home and subsequently called to gather more information. It was revealed that the nurse on duty at the time of the incident did not follow the reporting requirement to notify the DON, resulting in a delay in reporting the incident to the State Agency. The DON reported the incident as soon as she became aware, but acknowledged that it should have been reported within the mandated two-hour period.
Inadequate Investigation of Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation of an abuse allegation involving a resident, identified as R11, who was cognitively intact with a BIMS score of 15 out of 15. R11 reported to the Director of Nurses (DON) that on December 25, 2024, a Certified Nurse Aide (CNA9) was rough during care, specifically pulling on his genitals. Despite R11's report, the facility's investigation was insufficient as it only included an interview with one female resident and did not involve other male residents who received care from CNA9 on the same day. The facility's policy on abuse and neglect requires that all persons involved or with knowledge of the occurrence be interviewed. However, the investigation did not adhere to this policy, as it lacked interviews with other male residents who could have provided relevant information about CNA9's conduct. The DON acknowledged that the investigation should have included interviews with other male residents, indicating a lapse in following the facility's established procedures for handling abuse allegations.
Improper Mattress Fit Creates Hazard for Resident
Penalty
Summary
The facility failed to ensure that a resident's mattress fit the bed frame properly, creating a potential hazard. The resident, who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, was observed with a significant gap between the mattress and the footboard of the bed. This gap measured 11 inches during one observation and six inches during another, posing a risk of the resident's feet becoming entangled. The resident confirmed that she had slid down towards the footboard and had her feet entangled in the gap on previous occasions. During an observation with the Administrator, Director of Nurses (DON), and Nurse Consultants, the gap was measured and confirmed to be six inches. The resident reiterated that her feet had gotten caught in the gap when the bed was adjusted. Despite being asked, the facility did not provide a policy on ensuring that residents' mattresses fit bed frames properly by the time of the survey exit.
Resident Lacked Alternative Call Light Device
Penalty
Summary
The facility failed to ensure that a resident had an alternative call light device available when the call light system malfunctioned. Resident 50, who was admitted with chronic obstructive pulmonary disease, congestive heart failure with hypoxia, and interstitial pulmonary disease, was found without a call light or substitute device. The resident, who was severely cognitively impaired with a BIMS score of six out of 15, stated that the previous call light device had broken and that they had no means to call for assistance other than using their voice. The facility's call light system had failed in May 2024, and while most rooms were restored to normal functioning, two rooms, including the one occupied by Resident 50, remained without a functioning system due to wiring issues. Although other residents in similar situations were provided with doorbell-like devices, Resident 50 did not have such a device. The facility's staff, including the Administrator and DON, were aware of the issue, and the Administrator acknowledged that CNAs were instructed to check on residents and ensure they had a bell. However, during an interview, a CNA was unsure of what happened to Resident 50's bell.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Dover
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westminster Village Health | 0.5 mi | ★★★★★ | 13 | 1 |
| Complete Care At Silver Lake Llc | 1.1 mi | ★★★★★ | 13 | 0 |
| Center At Eden Hill, Llc | 1.5 mi | ★★★★★ | 3 | 0 |
| Bay Terrace Rehabilitation And Health Center | 2.9 mi | ★★★★★ | 6 | 1 |
| Evergreen Post Acute | 6.8 mi | ★★★★★ | 5 | 0 |
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