R114's fluid consumption dropped from 1,560 milliliters daily to just 300 milliliters in the days before her January transfer to the hospital. Her blood urea nitrogen level reached 100 — nearly five times the normal range — indicating severe dehydration and kidney dysfunction.
She died at the hospital days later.
Federal inspectors found that facility staff documented R114's dramatically reduced intake but failed to notify doctors or implement additional interventions as her condition deteriorated. The 88-year-old resident, who had dementia and stroke-related swallowing difficulties, required supervision and cueing for meals.
R114's decline began after she was placed in isolation following a COVID exposure. Her fluid intake in the four days before isolation ranged from 1,320 to 1,560 milliliters daily. Once isolated, her consumption plummeted.
On six of seven isolation days, her intake fell significantly below normal levels. She consumed only 880 milliliters one day, 780 another. Staff documented that she failed to eat entire meals five times during this period — 25 percent of all meals offered.
The facility's own care plan required staff to "monitor intake and record every meal" and "provide assistance cueing meals as needed." R114 was supposed to receive 1,200 to 1,440 milliliters of fluid daily, plus an additional 360 milliliters through medication passes.
Despite five consecutive days of poor intake, no staff member notified R114's medical providers until the morning of her hospitalization. A licensed practical nurse finally documented "hydration unsuccessful" at 6:23 a.m. on transfer day, after R114 had consumed only 300 milliliters and missed both breakfast and lunch entirely.
Paramedics found R114 with an altered mental status, rapid heart rate of 170 beats per minute, and rapid breathing at 40 breaths per minute. Her mouth was dry, they noted.
Hospital lab work revealed the extent of her dehydration. Her blood urea nitrogen measured 101 milligrams per deciliter — the normal range is 8 to 22. Her sodium level reached 157, well above the normal range of 136 to 145. Her creatinine, measuring kidney function, spiked to 2.21 from a baseline of 0.9.
Hospital doctors diagnosed sepsis with multi-organ failure affecting her kidneys and liver, plus new-onset atrial fibrillation.
The inspection also revealed failures in basic catheter care for another resident. R73, who had an indwelling urinary catheter due to urinary retention, was observed three times with his collection bag positioned above bladder level — a violation of infection control protocols that can cause urine to flow backward.
Facility policy and R73's care plan specifically required positioning the catheter bag below bladder level. Staff observed R73 in his wheelchair during lunch with the bag hanging above his bladder, attached to the left armrest.
A third resident, R101, struggled with communication due to hearing loss that staff failed to address. The cognitively intact stroke survivor told inspectors through written notes that she had requested hearing aids but "did not hear back" from facility staff.
"I would really like to hear a little better," R101 wrote to inspectors who found no communication devices in her room.
R101's family member confirmed bringing an amplifier during admission and agreeing to hearing aids when staff asked. "We said yes but I did not hear anything back about it since then," the relative told inspectors by phone.
Nursing assistants reported having to speak loudly into R101's left ear to communicate, sometimes confusing her roommate. Despite documented hearing difficulties and care plan interventions for communication deficits, the facility provided no alternative communication tools.
The facility also failed to update care plans after a resident-to-resident assault. R78 hit R66 in the face in March 2024, prompting safety interventions including hourly checks. But staff never revised R78's care plan for physical aggression to include the new monitoring requirements.
Another resident, R66, fell repeatedly while attempting to reach the bathroom, but staff failed to adjust her toileting schedule. Four documented falls between March and August 2024 occurred when R66 was trying to use the bathroom, including one where she was found sitting on the floor next to the toilet at 1:29 a.m.
Staff confirmed R66 was continent and asked for bathroom assistance, yet her personalized toileting program remained unchanged despite the pattern of bathroom-related falls.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cadia Rehabilitation Broadmeadow from 2025-01-22 including all violations, facility responses, and corrective action plans.
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