Cadia Rehab Broadmeadow: Accident Hazard Harm - DE
The nursing assistant, a CNA with four years of experience but new to the facility, told inspectors she had been assigned to the resident and rolled her onto her side to clean her. "She rolled out of the bed on to her face," the aide said.
She had no idea a second person was supposed to be there. She said she was told the resident's care information was in a closet but was never shown where. She had watched other aides care for the resident by themselves. Nobody told her otherwise.
The resident was hospitalized. As of the facility's five-day follow-up report, she had not returned.
When inspectors asked the nursing home administrator what the facility's investigation found to be the root cause of the fall, he said the aide had not positioned the resident properly. He did not mention the two-person requirement. When the inspector pressed him directly, asking whether the facility had identified that the care plan for two-person assistance during side-to-side rolling had not been followed, the administrator said the resident did not need to be rolled side to side for incontinence care.
The CNA had already told inspectors the resident could do nothing for herself. "The staff did everything for her," she said.
The facility's own plan of correction, submitted to inspectors as an undated document, acknowledged that the CNA "did not safely position the resident during incontinence care." Staff were re-educated and the aide was suspended. A house-wide audit of mobility care plans found no other issues.
Inspectors disagreed with that conclusion. The investigation, they found, had failed entirely to identify what actually went wrong: a fully dependent woman had a care plan requiring two people to turn her in bed, and the facility sent one person who had never been shown that requirement existed.
The resident remained hospitalized.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cadia Rehabilitation Broadmeadow from 2025-11-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
CADIA REHABILITATION BROADMEADOW in MIDDLETOWN, DE was cited for violations during a health inspection on November 14, 2025.
"She rolled out of the bed on to her face," the aide said.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.