WILMINGTON, DE - Federal inspectors cited Cadia Rehabilitation Silverside for immediate jeopardy violations after discovering the facility failed to report alleged abuse for four days, allowing an accused nursing aide to continue working with vulnerable residents.
Critical Reporting Failures Put Residents at Risk
The March 2025 inspection revealed that a certified nursing assistant stuck her tongue out at a cognitively impaired resident and threw three wipes at the resident's head during personal care on July 7, 2024. Despite being witnessed by another aide who reported the incident to a nurse the same day, facility administrators were not notified until July 11, 2024.
During this four-day delay, the accused aide continued her regular work schedule, caring for residents on July 8, 10, and 11. Federal regulations require nursing homes to report abuse allegations to state authorities within two hours of discovery.
The resident involved was severely cognitively impaired with a score of five out of 15 on mental status testing and had diagnoses including dementia with agitation and major depressive disorder. According to the aide's written statement, she "stuck my tongue out at R80 in response to a comment from her" and acknowledged throwing "three wipes at her playing around."
Pattern of Procedural Violations
Beyond the abuse reporting failure, inspectors documented multiple instances where staff violated infection control protocols and medication administration procedures. These violations affected the majority of residents at the 3322 Silverside Road facility.
Infection Control Breaches
Staff repeatedly failed to follow Enhanced Barrier Precautions (EBP) and Contact Precautions designed to prevent the spread of multidrug-resistant organisms. Inspectors observed:
- A licensed practical nurse entering an EBP room without protective equipment while hanging tube feeding, then dropping sterile tubing on the floor and using it anyway - Nursing supervisors entering isolation rooms without proper hand hygiene or protective gear - Housekeeping staff cleaning Contact Precaution rooms without gowns or gloves, potentially spreading dangerous bacteria like ESBL (extended-spectrum beta-lactamase)
These violations are particularly concerning because residents with feeding tubes, catheters, and wounds are already vulnerable to serious infections. ESBL bacteria are resistant to many common antibiotics, making infections extremely difficult to treat and potentially life-threatening for elderly residents.
Medication Safety Failures
The inspection revealed a 10% medication error rate - double the federal standard of 5%. Staff administered critical medications at incorrect times, potentially reducing their effectiveness:
- Diabetes medication (glipizide) given after meals instead of 30 minutes before, which can affect blood sugar control - ADHD medication (methylphenidate) and acid reflux medication (omeprazole) administered after breakfast instead of before meals as ordered
Proper timing of medications is crucial for their effectiveness. Diabetes medications work best when taken before meals to help control blood sugar spikes from food. Taking them after eating can lead to poor glucose control and long-term complications.
Fall Prevention Protocols Ignored
Inspectors found that ordered fall prevention measures were not being implemented for a resident with cognitive impairment who had previously fallen and sustained pelvic and shoulder fractures. Despite physician orders for a low bed and bilateral floor mats, staff kept the resident's bed at standard height without protective mats during multiple observations over three days.
Falls are a leading cause of injury and death in nursing homes. For residents with cognitive impairment and previous fractures, proper fall prevention interventions are essential to prevent serious reinjury.
Investigation Inadequacies
The facility also failed to properly investigate an injury of unknown origin. When a resident's thumb showed purple bruising and swelling after an altercation with staff, administrators ruled out staff abuse but conducted no further investigation to determine how the injury occurred. Federal regulations require thorough investigation of all unexplained injuries to ensure resident safety.
Missing Heart Rate Monitoring
Nurses failed to check a resident's heart rate before administering propranolol, a medication that can dangerously slow the heartbeat. The physician specifically ordered heart rate monitoring with instructions to hold the medication if the rate dropped below 50 beats per minute. Missing these vital checks occurred on multiple occasions, potentially putting the resident at risk for cardiac complications.
Immediate Corrective Actions Required
The facility implemented a removal plan in July 2024 and achieved substantial compliance by addressing the abuse reporting failure. Staff received additional training on proper reporting procedures, and the accused aide was terminated following investigation.
However, the March 2025 inspection revealed ongoing issues with infection control, medication administration, and safety protocols that affect daily resident care. These violations demonstrate systemic problems that extend beyond individual incidents.
Federal nursing home regulations exist to protect vulnerable residents who cannot advocate for themselves. When facilities fail to follow basic safety protocols - from reporting abuse promptly to preventing infections and administering medications correctly - they put residents at unnecessary risk.
Families considering nursing home placement should review inspection reports and ask facilities about their procedures for handling allegations of abuse, preventing infections, and ensuring medication safety. The complete inspection report contains additional details about corrective measures and ongoing monitoring requirements.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cadia Rehabilitation Silverside from 2025-03-27 including all violations, facility responses, and corrective action plans.
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