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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 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.