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Complaint Investigation

Cadia Rehabilitation Broadmeadow

January 22, 2025 · Middletown, DE · 500 South Broad Street
Citations 8
CMS Rating 1/5
Beds 120
Provider ID 085050
Healthcare Facility
Cadia Rehabilitation Broadmeadow
Middletown, DE  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

CADIA REHABILITATION BROADMEADOW in MIDDLETOWN, DE — inspection on January 22, 2025.

Found 8 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0600
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical

(ADON), E8 (Staff Educator), E14 (COO) and E15 (CNO).

085050 01/22/2025

Cadia Rehabilitation Broadmeadow 500 South Broad Street Middletown, DE 19709

reviewed, and revised by a team of health professionals.

sampled residents, the facility failed to ensure that R78's comprehensive care plan was reviewed and

Findings include: Cross refer F-F600 R78's clinical record revealed: 4/25/23 - R78 was care planned for potential physically aggressive behaviors as evidenced by yelling, kicking, hitting, slapping, striking out, etc.

Interventions included: - allowing R78 10-15 minutes to calm down then reapproach, - redirecting when visibly irritated and, - speaking in a calm voice to keep R78 calm, and feel non threatened. 3/25/24 9:37 PM - A facility incident report submitted to the State Agency documented that R78 hit R66 on the face. 4/2/24 - A facility 5 day follow up summary documented, Were changes made to Care Plan? Yes .

Medication changes; Q 1 hr (hour) safety check. 1/16/23 11:05 AM - A review of R78's potential for physical aggression care plan revealed that it was not revised to include the new safety check interventions. 1/16/2 1:46 PM - In an interview, E2 (DON) confirmed that R78's care plan for physical aggression was not revised and updated after the 3/25/24 resident - to - resident physical altercation between R78 and R66. 1/22/25 at 3:04 PM - Finding was reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), E8 (Staff Educator), E14 (COO) and E15 (CNO).

085050 01/22/2025

Cadia Rehabilitation Broadmeadow 500 South Broad Street Middletown, DE 19709

appointments.

refused.

She would say she wants them but refuses when offered. 1/21/25 8:07 AM - R101 was observed in her room, no evidence of communication tools or devices were seen in the room. 1/21/25 9:30 AM -

During an interview E18 (CNA) stated, I have to get very close to [R101] and talk loudly to her in her left ear. It's hard because her roommate sometimes think I am talking to her. 1/21/25 10:30 AM - During a telephone interview F3 (Family member) stated, I had brought an amplifier to use during the admission in September.

They [the facility] had asked me and my aunt about getting her hearing aids. We said yes but I did not hear anything back about it since then. I would like her to be able to hear better. 1/22/25 at 3:04 PM - Finding was reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), E8 (Staff Educator), E14 (COO) and E15 (CNO).

085050 01/22/2025

Cadia Rehabilitation Broadmeadow 500 South Broad Street Middletown, DE 19709

The facility failed to ensure R66's person centered care plan interventions and a personalized toileting program were reviewed to address R66's falls related to R66's need to use the bathroom. 1/21/25 2:40 PM - Findings were discussed with E1 (NHA) and E2. 1/22/25 at 3:04 PM - Finding was reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), E8 (Staff Educator), E14 (COO) and E15 (CNO).

085050 01/22/2025

Cadia Rehabilitation Broadmeadow 500 South Broad Street Middletown, DE 19709

related to R97 utilizing a [NAME] adaptive cup outside of her meal tray.

1/16/25 2:45 PM -

During an interview, E24 (CNA) stated, When we pass the [bedside] water, we use the white styrofoam cups for [R97].

There is no any documentation in the tasks regarding specialty cups.

There is not an order. If there3 is a specialty cup on her bedside table, I would pour the water from the styrofoam cup to the specialty cup.

Most times, the specil cups come on the food trays. 1/21/25 3:28 PM - E15 (CNO) presented the surveyor with a copy of a new order for R97 stating offer water in Kennedy cup q (every) shift. E15 also provided a copy of R97's CNA tasks list report with a new task Provide Q (every) shift water in Kennedy cup. 1/22/25 3:04 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), E8 (Staff Educator), E14 (COO) and E15 (CNO).

The surveyor wrote the questions on paper and asked R101 if she could hear what was being said. R101 wrote, No and pointed to her right ear and, little for her left hear.

The surveyor further inquired if R101 had any tools e.g. white board or writing paper to communicate with staff, R101 shook her head from side to side, and wrote No. I asked for hearing aids but did not hear back. I would really like to hear a little better.

R101's room lacked evidence of writing paper, white board, or any other type of communication devices.

085050

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 085050 B.

Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cadia Rehabilitation Broadmeadow 500 South Broad Street Middletown, DE 19709

A review of R78's clinical record revealed the following:

2/22/23 - R78 was admitted to the facility with diagnoses including but not limited to dementia, depression, and anxiety disorder.

3/6/23 - R78 was care planned for impaired cognition and interventions included to cue, reorient and supervise as needed and to .monitor/document/report when necessary any changes in cognitive function, . changes in: .difficulty expressing self, difficulty understanding others .

4/25/23 - R78 was care planned for potential physically aggressive behaviors as evidenced by yelling, kicking, hitting, slapping, striking out, etc.

Interventions included: allowing R78 10 - 15 minutes to calm down and then reapproach, redirecting when visibly irritated and speaking in a calm voice to keep R78 calm and feel non threatened.

1/25/24 - A review of R66's quarterly MDS assessment revealed that R66's cognition was moderately intact and had used a manual wheelchair for mobility during the review period.

2/15/24 - R78's annual MDS assessment revealed that R78's cognition was moderately impaired, had physical and verbal behaviors occurring 1 to 3 days and had used a manual wheelchair for mobility during the review period.

3/25/24 9:37 PM - A facility incident report submitted to the State Agency documented that on 3/25/24 at 6:20 PM, .After dinner resident [R66] reported to the charge nurse that another resident [R78] hit her on the face and found redness on the left eyelid.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

085050

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 085050 B.

Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cadia Rehabilitation Broadmeadow 500 South Broad Street Middletown, DE 19709

Review of R97's clinical record revealed:

[DATE] - R97 was admitted to the facility with diagnoses including but were not limited to, dementia and difficulty swallowing.

[DATE] 9:56 AM - E13 (dietician) documented on the [facility] Nutrition Risk Assessment in R97's EMR, .

Estimated fluids- ml (milliliter) - 1500 - 1800 ml (,d+[DATE] ml/kg) (kilogram) .

Feeding status - Needs some assistance with meal set up or eating .

Assessment - .Daughter reports good oral intake but has had to assist with meals .

[DATE] 10:05 AM - E13 (dietician) ordered in R97S EMR, Regular diet .Adaptove equipment: please issue divided plate, built up utensils ands [NAME] cup with straw at all meals.

[DATE] 1:00 PM - E27 (MD) ordered in R97's EMR, Med Pass one time a day 120 mls and Juven two times a day for 4 weeks.

Mix with 240 mls water.

These two orders accounted for 600 mls of R97's documented oral intake during this time period.

[DATE] - R97 was care planned for several problems including: .(1) a potential nutritional problem r/t (related to) advanced age, . self-feeding difficulty requiring adaptive equipment .

Interventions for this problem included: provide adaptive equipment for feeding as needed .Monitor intake and record .[R97] has an ADL (activities of daily living) self-care performance deficit r/t limited mobility . (2) has impaired cognitive function/dementia .

Interventions for this problem included: Cue, reorient and supervise as needed . (3) has an ADL (activities of daily living) self-care performance deficit r/t (related to) limited mobility .Interventions for this problem included: Assist with eating as needed .

The daily totals of R97's fluid intake were:

[DATE] - 1440 mls

[DATE] - 1200 mls.

085050

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 085050 B.

Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cadia Rehabilitation Broadmeadow 500 South Broad Street Middletown, DE 19709

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MIDDLETOWN, DE, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CADIA REHABILITATION BROADMEADOW or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.