Deficiencies (last 3 years)
Deficiencies (over 3 years)
15 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
70% worse than Delaware average
Delaware average: 8.8 deficiencies/yearDeficiencies per year
32
24
16
8
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 14, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident fall and the facility's failure to provide adequate supervision to prevent accidents.
Complaint Details
The complaint investigation substantiated that the facility failed to provide adequate supervision to resident R1, who required two-person assistance for rolling and transfers. The resident fell from bed while being cared for by a single aide, resulting in multiple fractures and a splenic laceration.
Findings
The facility failed to ensure adequate supervision for a completely dependent resident (R1), resulting in a fall from bed causing multiple fractures and a splenic laceration. The care plan required two-person assistance for transfers and rolling, but the resident was cared for by a single aide, leading to the fall and harm.
Deficiencies (1)
F 0689: The facility failed to ensure that a nursing home area was free from accident hazards and provided adequate supervision to prevent accidents. A resident fell from bed due to insufficient staff assistance during care, resulting in serious injuries.
Report Facts
Fall risk score: 5
Date of fall: Nov 7, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E5 | Certified Nursing Assistant (CNA) | Named in the finding as the aide who rolled the resident onto her side alone, leading to the fall. |
| E1 | Nursing Home Administrator (NHA) | Participated in interviews and exit conference regarding the fall investigation. |
| E2 | Director of Nursing (DON) | Participated in interviews and exit conference regarding the fall investigation. |
| E7 | Utilization Manager (UM) | Provided information about resident transfer and bed mobility status. |
| E4 | Occupational Therapist (OT) | Provided information about resident assistance needs. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jul 7, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide timely and appropriate emergency care, including failure to initiate CPR and report neglect after a resident (R1) had a choking episode and subsequent cardiac arrest.
Complaint Details
The complaint investigation substantiated that the facility failed to provide appropriate emergency care and failed to report neglect after a resident choking incident. Immediate jeopardy was identified due to failure to initiate CPR and inadequate nursing competencies, resulting in resident death.
Findings
The facility failed to identify and report an allegation of neglect when staff did not provide essential lifesaving interventions for R1 during a choking episode. The nursing staff failed to assess R1's airway, initiate CPR despite R1's full code status, and provide competent emergency care, resulting in R1's death. The facility also lacked adequate staff training and assessment of nursing competencies for emergency situations.
Deficiencies (4)
F0609: The facility failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities after a resident choking incident.
F0678: The facility failed to provide basic life support, including CPR, prior to the arrival of emergency medical personnel for a resident who was choking and became unresponsive.
F0726: The facility failed to ensure nurses and nurse aides had the appropriate competencies to care for residents, resulting in failure to recognize and respond to an emergent choking and respiratory distress situation.
F0838: The facility failed to conduct and document a facility-wide assessment to determine necessary resources and staff competencies for competent resident care during emergencies.
Report Facts
Oxygen saturation: 64
Heart rate: 149
Date of Immediate Jeopardy call: Jul 3, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E8 | Licensed Practical Nurse (LPN) | Notified of resident choking, failed to listen to lungs or initiate CPR |
| E7 | Registered Nurse Supervisor (RN Supervisor) | Did not assess resident airway or respiratory status, called 911, provided in-service training |
| E2 | Director of Nursing (DON) | Unaware of neglect allegations and stated staff reported resident was responsive |
| E9 | Paramedic | Arrived on scene, found resident pulseless and initiated CPR |
| F1 | Resident's wife | Reported resident choking and informed staff |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jan 22, 2025
Visit Reason
The inspection was conducted following a complaint investigation regarding resident-to-resident physical abuse and other care concerns at Cadia Rehabilitation Broadmeadow.
Complaint Details
The complaint investigation substantiated that resident R66 was physically abused by resident R78. Additional findings included failure to revise care plans, inadequate hearing support, improper catheter and continence care, and insufficient hydration leading to harm.
Findings
The facility failed to ensure resident R66 was free from physical abuse by resident R78 and failed to revise R78's care plan accordingly. Additionally, the facility did not provide adequate hearing support for resident R101, failed to provide appropriate catheter and continence care for residents R73 and R66, and failed to ensure proper hydration for residents R97 and R114, resulting in actual harm to R114.
Deficiencies (5)
F0600: The facility failed to protect resident R66 from physical abuse by resident R78 on 3/24/24.
F0657: The facility failed to revise resident R78's comprehensive care plan after a physical altercation with resident R66 on 3/25/24.
F0685: The facility failed to provide adequate care to support resident R101's hearing loss, including lack of communication tools and follow-up on hearing aids.
F0690: The facility failed to provide appropriate catheter care for resident R73 and failed to maintain or restore continence and address falls related to toileting needs for resident R66.
F0692: The facility failed to ensure residents R97 and R114 received sufficient fluids to maintain hydration, resulting in actual harm to R114 who was hospitalized and later expired.
Report Facts
Date of survey completion: Jan 22, 2025
BUN level: 100
BUN level: 61
Fluid intake: 1500
Fluid intake: 1440
Fluid intake: 1560
Number of residents reviewed for abuse: 6
Number of residents reviewed for hearing loss: 3
Number of residents reviewed for bowel/bladder care: 3
Number of residents reviewed for hydration: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Director of Nursing (DON) | Confirmed failure to revise R78's care plan and discussed findings |
| E1 | Nursing Home Administrator (NHA) | Discussed findings during exit conference |
| E3 | Assistant Director of Nursing (ADON) | Participated in exit conference |
| E8 | Staff Educator | Participated in exit conference and confirmed catheter care observations |
| E14 | Chief Operating Officer (COO) | Participated in exit conference |
| E15 | Chief Nursing Officer (CNO) | Participated in exit conference and presented new hydration order for R97 |
| E24 | Certified Nursing Assistant (CNA) | Provided information on toileting assistance for R66 and hydration practices for R97 |
| E36 | Licensed Practical Nurse (LPN) | Documented hydration unsuccessful for R114 |
| E29 | Nurse Practitioner (NP) | Reviewed lab results for R97 |
| E4 | Registered Nurse (RN)/Unit Manager | Provided interview regarding R114's behavior and hydration |
| E30 | Licensed Practical Nurse (LPN) | Reported on R97's use of adaptive cups |
| E32 | Occupational Therapist (OT) | Reported on R97's specialized dining utensils |
Inspection Report
Annual Inspection
Deficiencies: 19
Date: Jan 22, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements across multiple areas including resident care, medication management, infection control, and facility operations.
Findings
The facility was found to have multiple deficiencies including failure to treat residents with dignity, inaccurate resident assessments, incomplete care plans, failure to notify appropriate authorities for mental health diagnoses, delayed treatment of infections, inadequate hearing support, improper catheter care, insufficient hydration, missed physician visits, incomplete medication reviews, improper food storage, incomplete medical records, improper arbitration agreement procedures, and failure to follow infection control protocols.
Deficiencies (19)
F0550: The facility failed to ensure residents were treated with respect and dignity, evidenced by staff calling a resident a 'slowpoke' in the presence of others.
F0641: The facility failed to accurately assess residents' conditions, including failure to document pressure injuries and dental issues.
F0646: The facility failed to notify appropriate authorities of significant changes in residents with mental disorders and failed to request required PASARR reviews.
F0656: The facility failed to develop and implement comprehensive, person-centered care plans including non-pharmacological interventions prior to PRN medication use and failed to revise care plans after incidents.
F0657: The facility failed to review and revise a resident's comprehensive care plan based on current needs and preferences after a physical aggression incident.
F0661: The facility failed to provide a discharge summary that included medication reconciliation and complete medication information at discharge.
F0684: The facility failed to treat a urinary tract infection for 20 hours after receiving positive lab results.
F0685: The facility failed to provide appropriate care to support a resident's hearing loss, including failure to provide communication tools or hearing aids.
F0690: The facility failed to provide appropriate catheter care and failed to maintain or restore continence, resulting in falls and inadequate toileting programs.
F0692: The facility failed to ensure residents received sufficient hydration and failed to respond to decreased oral intake, resulting in harm and hospitalization.
F0712: The facility failed to ensure required physician visits were coordinated and alternated with nurse practitioner visits, resulting in missed required visits.
F0756: The facility failed to ensure provider documentation of medication irregularities and lacked time frame requirements in the drug regimen review policy.
F0758: The facility failed to document targeted behaviors and non-pharmacological interventions prior to PRN antianxiety medication administration.
F0773: The facility failed to obtain laboratory services only when ordered by a provider.
F0810: The facility failed to provide a resident with an adaptive cup for independent drinking during non-meal times.
F0812: The facility failed to store and serve food in a manner that prevents foodborne illness, including undated opened food items and incomplete temperature logs.
F0842: The facility failed to ensure the electronic health record was complete and readily accessible, missing detailed physician progress notes.
F0847: The facility failed to ensure residents with cognitive impairment were capable of understanding arbitration agreements prior to signing and failed to involve emergency contacts.
F0880: The facility failed to ensure staff wore appropriate PPE while administering medications via a PEG tube under Enhanced Barrier Precautions.
Report Facts
Days without physician visit: 151
Days between physician visits: 231
BUN level: 61
BUN level: 100
Meals with unrecorded temperature: 22
PRN anti-anxiety medication uses without documentation: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | NHA | Reviewed findings during exit conferences. |
| E2 | DON | Reviewed findings during exit conferences and interviews. |
| E3 | ADON | Reviewed findings during exit conferences. |
| E8 | Staff Educator | Reviewed findings during exit conferences and confirmed medication documentation issues. |
| E14 | COO | Reviewed findings during exit conferences. |
| E15 | CNO | Reviewed findings during exit conferences and provided documentation. |
| E6 | NP | Confirmed delayed treatment of UTI and medication orders. |
| E30 | LPN | Observed administering medications without PPE and confirmed error. |
| E32 | OT | Confirmed adaptive cup orders and usage. |
| E4 | RN/Unit Manager | Provided information on resident hydration and behavior. |
| E24 | CNA | Provided information on resident toileting and hydration assistance. |
| E23 | LPN | Provided information on resident continence and toileting. |
| E27 | MD | Provided orders and progress notes; unable to access some notes. |
| E28 | NP | Provided progress notes and assessments. |
| E29 | NP | Provided progress notes and assessments. |
| E36 | LPN | Documented hydration concerns and lab progress notes. |
| E25 | Assistant Food Service Director | Confirmed food storage observations. |
| E12 | Food Service Director | Discussed food storage and temperature log findings. |
| E13 | Dietician | Provided dietary orders and assessments. |
| E16 | Admission Representative | Completed admission documents including arbitration agreement. |
| E17 | Admission Assistant Representative | Completed admission documents including arbitration agreement. |
| E22 | NP | Signed pharmacy recommendations and provided verbal orders. |
| E29 | NP | Reviewed lab results and assessments. |
| E6 | UM/RN | Confirmed pharmacy recommendation follow-up and treatment delays. |
Inspection Report
Deficiencies: 0
Date: Jan 12, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Cadia Rehabilitation Broadmeadow, summarizing the findings of a regulatory survey completed on January 12, 2024.
Findings
No health deficiencies were found during the survey.
Inspection Report
Annual Inspection
Deficiencies: 16
Date: Nov 10, 2021
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements across multiple care areas including resident rights, care planning, medication management, infection control, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to promote resident dignity during dining, inadequate accommodations for bed rail removal, restrictions on indoor visitation, failure to provide personal funds statements, delayed physician notification of new wounds, inaccurate MDS assessments, incomplete baseline and comprehensive care plans, failure to monitor fluid restrictions, expired medications in storage, failure to assist with dental services, and unsanitary food storage conditions.
Deficiencies (16)
F0550: The facility failed to ensure care was provided in a way that promoted dignity during dining for one resident due to disorganized meal tray distribution causing delayed meal delivery.
F0558: The facility failed to reasonably accommodate resident preferences when removing upper bed rails for three residents, causing fear of falling and lack of alternative accommodations.
F0563: The facility failed to ensure residents' right to receive visitors by placing no visitor signs and delaying reopening for indoor visitation for 10 days after COVID-19 outbreak clearance.
F0568: The facility failed to provide quarterly personal funds statements to two residents and did not maintain records of statement distribution.
F0580: The facility failed to immediately notify the physician and resident representative of a new sacral wound for one resident.
F0641: The facility failed to ensure an accurate MDS assessment for one resident by incorrectly documenting a prescribed weight-loss regimen.
F0655: The facility failed to develop baseline care plans within 48 hours of admission and failed to provide baseline care plan summaries to two residents.
F0656: The facility failed to develop and implement comprehensive person-centered care plans for two residents, omitting key care needs such as anemia management and meal set-up assistance.
F0657: The facility failed to update one resident's nutrition care plan to reflect current needs and failed to include required interdisciplinary team input.
F0684: The facility failed to ensure ordered laboratory tests were performed for one resident and failed to monitor fluid restrictions for two residents, resulting in noncompliance with physician orders.
F0677: The facility failed to provide necessary assistance with activities of daily living, specifically meal set-up and cutting meat, for one resident.
F0689: The facility failed to maintain a safe environment by not addressing a sliding mattress issue for one resident after bed rails were removed.
F0692: The facility failed to identify and reassess significant weight loss for one resident and failed to monitor fluid intake compliance.
F0761: The facility failed to discard expired medications and supplies from medication carts, including insulin and protein powder.
F0791: The facility failed to assist one resident in obtaining dental services despite a physician's order for dental consultation and treatment.
F0812: The facility failed to ensure food was stored, prepared, and served in a sanitary manner, including dirty equipment, expired food items, and unlabeled perishables in the kitchen.
Report Facts
Residents sampled for care areas: 27
Residents sampled for care plan review: 36
Residents reviewed for personal funds: 2
Residents reviewed for dental services: 4
Medication carts reviewed: 3
Days fluid restriction exceeded: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | NHA | Named in multiple findings and exit conferences |
| E2 | DON | Named in multiple findings and exit conferences |
| E18 | RN UM | Named in findings related to wound notification, care planning, and fluid restriction monitoring |
| E25 | RN UM | Named in findings related to dental services and visitation |
| E27 | Food Service Director | Named in findings related to kitchen sanitation |
| E17 | RN | Named in findings related to expired medication management |
| E19 | NP | Named in findings related to nutrition care plan and weight loss |
| E3 | ADON | Named in findings related to mattress safety and bed rail removal |
Report
November 14, 2025
Report
July 7, 2025
Report
January 22, 2025
Report
January 22, 2025
Report
January 12, 2024
Report
November 10, 2021
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