Cadia Rehabilitation Broadmeadow

F-F600

Resident R78's clinical record revealed:

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

- allowing Resident R78 10-15 minutes to calm down then reapproach,

- redirecting when visibly irritated and,

- speaking in a calm voice to keep Resident R78 calm, and feel non threatened.

3/25/24 9:37 PM - A facility incident report submitted to the State Agency documented that Resident R78 hit Resident 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 Resident 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 Resident R78's care plan for physical aggression was not revised and updated after the 3/25/24 resident - to - resident physical altercation between Resident R78 and Resident 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).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 32 085050 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or 46988 potential for actual harm Based on record review and interview, it was determined that for one (Resident R31) out of three residents reviewed Residents Affected - Few for quality of care, the facility failed to treat a urinary tract infection for twenty hours, after receiving a positive result of infection. Findings include:

Cross refer

F-F692

A Kennedy cup is an adaptive cup that prevents liquid from spilling even when turned upside down and has

an ergonomic handle for ease of holding.

Review of Resident R97's clinical record revealed:

12/19/24 - Resident R97 was admitted to the facility with diagnoses including but were not limited to, dementia and difficulty swallowing.

12/20/24 10:05 AM - E13 (dietician) ordered in Resident R97's EMR, Regular diet .Adaptive equipment: please issue divided plate, built up utensils and Kennedy cup with straw at all meals.

12/20/24 - Resident R97 was care planned for .a potential nutritional problem r/t (related to) advanced age . self-feeding difficulty requiring adaptive equipment .[Resident R97] has an ADL (activities of daily living) self-care performance deficit r/t limited mobility.

12/31/24 - Resident R97 was care planned for .[Resident R97] has actual contracture .decreased functional mobility .

1/13/25 4:06 PM - During an interview, F6 (Resident R97's daughter) stated that her mom [Resident R97] needs her bedside water in an adaptive cup. F6 stated, The staff gives her water every shift in a Styrofoam white cup and she [Resident R97] cannot pick it up due to her stroke. So only when the family or staff offer to hold her water cup can she drink it. She likes water and will drink it, if she could pick up the cup.

1/13/25 4:06 PM - The surveyor observed Resident R97's bedside table with a full, white Styrofoam cup with a straw and ice water in it.

1/14/25 10:30 AM - The surveyor observed Resident R97's bedside table with a full, white Styrofoam cup with a straw and ice water in it.

1/15/25 1:07 PM - During an interview, E32 (OT) stated, [Resident R97] is ordered specialized dining utensils. It is part of the diet order. The ([NAME]) cup is not left at the bedside because it has to be cleaned. Usually, I talk to

the family and have them buy another ([NAME]) cup for the resident to use for their water cup.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 32 085050 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0810 The facility failed to provide Resident R97 with an adaptive cup that she could independently drink from during non-meal times. Level of Harm - Minimal harm or potential for actual harm 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). Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 32 085050 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 51625

Residents Affected - Many Based on observation and interview, it was determined that the facility failed to ensure food was stored and served in a manner that prevents food borne illness to the residents. Findings include:

1. 1/13/25 9:03 AM - An observation in the dry storage room revealed several food item bags that were opened but not dated. There were three bags of bread and a bag of cake mix powder. The findings were confirmed with E25 (Assistant Food Service Director) on site.

2. 1/13/25 9:11 AM - An observation in the walk-in freezer revealed some food debris on the floor. An opened bag of shrimp did not have a date. The findings were confirmed with E25 on site.

3. 1/13/25 9:15 AM - An observation in the walk-in refrigerator revealed a dated half bag of poultry meat stored together with two bags of un-opened same type of poultry meat without dates. The surveyors were not certain whether they belonged to the same batch. There were also a bottle of apple juice and a grape jelly undated, and a discolored vegetable salad dated 1/3/25 which was removed by E25 upon noticed.

4. 1/14/25 2:17 PM - A review of the three-month food temperature log from October to December, 2024 revealed that the temperature of 22 out of 279 (7.9%) meals were not recorded in the log.

1/15/25 11:20 AM - Findings were discussed and confirmed with E12 (Food Service Director), E25 and E13 (Registered Dietitian).

1/15/25 11:55 AM - Findings were discussed with E1 (NHA) and E2 (DON).

1/22/25 at 3:04 PM - Findings were reviewed during the exit conference with E1, E2, E3 (ADON), E8 (Staff Educator), E14 (COO) and E15 (CNO).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 32 085050 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 32545

Residents Affected - Few Based on record review and interview, it was determined that for one (Resident R109) out of twenty seven residents reviewed, the facility failed to ensure that the electronic health record was complete and readily accessible. Findings include:

Resident R109's clinical record revealed:

11/27/24 - Resident R109 was admitted to the facility for a principal diagnosis of a fracture and short term therapy.

12/16/24 - Resident R109 was diagnosed with clostridium difficile (Cdiff) and was placed on an antibiotic for 10 days.

12/27/24 at 2:21 PM - A Physician progress note documented, Pt seen and examined. Progress note to follow.

1/16/25 - Review of Resident R109's clinicial record lacked evidence of the detailed 12/27/24 Physician progress note.

1/17/25 - Resident R109 was discharged from the facility.

1/22/25 at 1:51 PM - During an interview, E27 (Physician) was asked about the 12/27/24 progress note. E27 stated that since the resident was discharged , she was unable to access it at the time of the interview on her cell phone. When asked about how the resident's Physician progress notes are included into the facility's electronic clinical record, E27 stated that the progress notes migrate over to the facility's clinical record after

they are electronically signed by the Provider. E27 stated that she was not aware how often the migration occurs.

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).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 32 085050 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Level of Harm - Minimal harm or 47621 potential for actual harm Based on record review and interview, it was determined that for two (Resident R3 and Resident R31) out of five residents Residents Affected - Few reviewed for arbitration agreements, the facility failed to ensure that Resident R3 and Resident R31 were capable of understanding the arbitration agreement prior to signing it. Findings include:

Basic Interview for Mental Status (BIMS) test is a standardized cognitive assessment tool mandatory in long-term care facilities in accordance with the Centers for Medicare and Medicaid Services (CMS). The BIMS score interpretation categorizes scores into groups by cognitive status. Any score of 13 to15 is classified as intact indicating normal cognitive response. The moderate impairment classification describes a score from 8 to 12 and suggests that the resident may need assistance with daily activities and may be in cognitive decline. The Severe impairment score indicates that the resident will have significant trouble with cognitive tasks and will likely need extensive help to navigate daily life. A BIMS score from 0 to 7 falls within

this classification. CMS website, 2025

1. Review of Resident R3's clinical record revealed:

5/1/24 - Resident R3 was admitted to the facility with diagnoses including, but were not limited to, dementia, anxiety disorder and cognitive communication deficit. Resident R3's Resident Information sheet named F1 (Resident R3's son) as emergency contact #1.

5/1/24 - E16 (admission representative) completed the facility admission documents with Resident R3. Resident R3 signed the legally binding arbitration agreement, which stated, . The parties understand and agree that by signing this arbitration agreement, they are giving up and waiving their statutory and constitutional rights to have any claim, including malpractice and wrongful death claims, decided in a court of law before a judge and jury . If

this Agreement is not rescinded within thirty (30) days of the date upon which it is signed, it is binding upon

the parties in all matters regarding care and services provided to the resident by the Facility, regardless of subsequent discharges and readmissions . This agreement does not terminate upon the end of the facility's provision of health care or other services to the Resident or upon termination of any other contract or agreement .

Despite having a diagnosis of dementia, the facility had Resident R3 sign multiple documents, including her Resident Admission agreement, Consent for Treatment and the binding arbitration agreement.

5/8/24 - Resident R3's admission MDS assessment revealed a Brief Interview for Mental Status (BIMS) score of seven, which was reflective of severe cognitive impairment.

The facility was unable to provide evidence of approaching Resident R3's emergency contact [F1] to review the binding arbitration agreement after determining Resident R3 had a severe cognitive impairment. This determination occurred just seven days after Resident R3's admission to the facility and was still within the 30 day window for the binding arbitration agreement to be rescinded.

2. Review of Resident R31's clinical record revealed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 32 085050 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0847 7/3/24 - Resident R31 was admitted to the facility with diagnoses including, but were not limited to, atrial fibrillation, cognitive communication deficit and adjustment disorder with anxiety. Resident R31's Resident Information sheet Level of Harm - Minimal harm or named F2 (Resident R31's daughter) as her emergency contact #1. potential for actual harm 7/5/24 - E17 (admission assistant representative) completed the facility admission documents with Resident R31. Resident R31 Residents Affected - Few signed the legally binding arbitration agreement, which stated, . The parties understand and agree that by signing this arbitration agreement, they are giving up and waiving their statutory and constitutional rights to have any claim, including malpractice and wrongful death claims, decided in a court of law before a judge and jury . If this Agreement is not rescinded within thirty (30) days of the date upon which it is signed, it is binding upon the parties in all matters regarding care and services provided to the resident by the Facility, regardless of subsequent discharges and readmissions . This agreement does not terminate upon the end of

the facility's provision of health care or other services to the Resident or upon termination of any other contract or agreement .

The facility had Resident R31 sign multiple documents including the Resident Admission agreement, Consent for Treatment and the binding arbitration agreement.

7/10/24 - Resident R31's admission MDS assessment revealed a BIMS score of ten, which was reflective of moderate cognitive impairment.

The facility was unable to provide evidence of approaching Resident R31's emergency contact [F2] to review the binding arbitration agreement after determining Resident R31 had a moderate cognitive impairment. This determination occurred just 7 days after Resident R31's admission to the facility and was still within the 30 day window for the binding arbitration agreement to be rescinded.

1/22/24 - 11:15 AM - During an interview, E1 (NHA) stated that the facility did not have a policy regarding the process/procedure of obtaining consents from resident with impaired cognition/below normal BIMS scores. E1 did confirm that all facility employees must complete training annually on compliance and ethics as part of

the facility's corporate compliance program.

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).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 32 085050 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 47621 potential for actual harm Based on record review, observation and interview, it was determined that for one (Resident R98) out of four residents Residents Affected - Few reviewed for medication administration, the facility failed to ensure the staff wore appropriate PPE while administering Resident R98's medications via her PEG tube. Findings include:

Facility's Infection Prevention and Control Policy Program: It is the policy of [facility] to maintain an Infection Prevention and Control program (IPCP) to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections .

Prevention/Isolation: Individuals with suspected or diagnosed communicable disease are placed on the appropriate precaution for that disease, as recommended by the Centers for disease Control and prevention (CDC). Review date: January 2, 2025

3/20/24 - CMS Memorandum (ref QSO-24-08-NH) stated, .In 2019, CDC introduced a new approach to the use of personal protective equipment (PPE) called Enhanced Barrier Precautions (EBP) as a strategy in nursing homes to decrease the transmission of CDC-targeted and epidemiologically important MDROs (multi-drug resistant organisms) when contact precautions do not apply . EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing . EBP are indicated for residents with any of the following: infection or colonization with CDC-targeted MDRO when contact precautions do not otherwise apply; or wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO .Indwelling medical device examples include central lines, urinary catheters, feeding tubes and tracheostomies .

12/16/24 - Resident R98 was admitted to the facility with diagnoses, including but were not limited to, stroke, swallowing difficulties and S/P percutaneous gastrostomy tube (PEG) in place.

12/18/24 - E27 (MD) ordered in Resident R98's electronic medical record (EMR), .Enhanced Barrier precautions r/t (related to) presence of enteral (pertaining to small intestines) tube, history of VRE (vancomycin resistant enterococcus, a MDRO bacteria) and ESBL (extended spectrum beta-lactamase, a MDRO bacteria) .

The indwelling medical device (feeding tube) and the two CDC-targeted MDROs require the use of PPE for Enhanced Barrier precautions.

1/14/25 11:30 AM - the facility was unable to provide evidence of a specific Enhanced Barrier Precaution policy when requested by the surveyor.

1/15/25 10:11 AM - Surveyor observed E30 (LPN) administer nine medications to Resident R98 via Resident R98's PEG feeding tube during med pas facility task. E30 failed to don the required yellow isolation gown while accessing Resident R98's indwelling medical device (PEG feeding tube).

1/15/25 10:35 AM - During an interview, E30 (LPN) stated, .That was high-contact care. You're right. I should have had a yellow gown on .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 32 085050 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 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). Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 32 085050

F-F773

Review of Resident R31's clinical record revealed:

11/3/23 - Resident R31 was admittied to the facility.

3/6/25 12:45 AM - A physician's order documented to obtain a urinalysis, if the urinalysis was positve send for culture and sensitivity for increased confusion and lethargy.

3/9/25 8:03 PM - A lab result report received in the facility EMR system documented that Resident R31's urinalysis noted culture growth of escherichia coli (e coli) with a colony count greater than 100,000 cfu/mL indicating a postive result for urinary tract infection.

3/10/25 9:01 AM - A time stamp noted in the EMR that E6 (NP) reviewed the urine results on the lab result report. The was 11 hours after the facility received the results of a positive UTI.

3/10/25 4:00 PM - A physician's order documented ceftriaxone (antibiotic) one gram inject one gram intramuscularly every twenty four hours for UTI (urinary tract infection) for five days. Give with lidocaine 2.1 mL. This was seven hours after the provider reviewed the positive lab results for a UTI.

3/10/25 4:27 PM - A review of Resident R31's MAR documented that ceftriaxone was administered.

3/10/25 7:00 PM - A change in condition assessment documented Resident R31 was having mental status changes, unable to respond properly to questions asked, lethargy, and neurological changes, and not able to focus.

The assessment documented a recommendation of the primary clinician that Resident R31 to be sent to the emergency room for further evaluation.

3/27/25 3:00 PM - An interview with E6 confirmed that Resident R31 had a positive urine culture and that E6 ordered antibiotics. E6 confirmed that she instructed the 3:00 PM to 11:00 PM shift to send Resident R31 to the emergency room due to change in condition. E6 further revealed that staff did not call the urine results to her on 3/9/25.

3/28/25 9:15 AM - An interview with E6 confirmed that she reviewed Resident R31's urine results at 9:00 AM on 3/10/25 and confirmed that Resident R31 needed antibiotics to treat the UTI. E6 stated that she did not need to wait

on Resident R31's lab results collected on 3/10/25 to initiate the antibiotics for the UTI.

The facility failed to treat a UTI for 20 hours after the facility received a positive lab result.

3/28/25 3:21 PM - Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 32 085050 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0685 Assist a resident in gaining access to vision and hearing services.

Level of Harm - Minimal harm or 48409 potential for actual harm Based on record review, observation and interview, it was determined that for one (Resident R101) out of three Residents Affected - Few sampled residents, the facility failed to ensure that care was provided to support Resident R101's hearing loss. Findings include:

Review of Resident R101's clinical records revealed:

9/17/24 - Resident R101 was admitted to the facility with diagnoses including stroke, cognitive communication deficit and major depressive disorder.

9/23/24 - Resident R101's admission MDS documented, Minimum hearing difficulty.

9/30/24 - Resident R101's admission BIMS documented a score of 15, indicating a cognitively intact status.

9/30/24 - Resident R101's communication care plan documented, .[Resident R101] has a communication problem r/t [related to] hearing deficit The interventions included, Allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, face when speaking, make eye contact, turn off tv/radio to reduce environmental noise, ask yes/no questions if appropriate, use simple, brief, consistent words/cues, use alternative communication tools as needed .

11/16/24 - Resident R101 clinical records documented, Seen by audiologist - recommendation for debrox [ear wax softening medication] 5 drops to both ears x 7 days.

12/18/24 - Resident R101's clinical records documented, .Seen by audiologist - [wax] was removed from ears.

12/19/24 - Resident R101's quarterly MDS documented a BIMS score of 14, indicating a cognitively intact status.

12/19/24 - Resident R101's clinical document titled, Cadia Social Services Assessment documented, [E101] declined dentist, hygienist, hearing, sight this quarter

Resident R101's clinical records documented eye doctor and audiologist visits in November and December 2024.

12/24/24 - Resident R101's quarterly MDS documented, Moderate hearing difficulty follow up with audiology.

1/14/25 9:00 AM - During an interview the Surveyor attempted to speak with Resident R101, but she pointed to both of her ears and shook her head. The surveyor wrote the questions on paper and asked Resident R101 if she could hear what was being said. Resident R101 wrote, No and pointed to her right ear and, little for her left hear. The surveyor further inquired if Resident R101 had any tools e.g. white board or writing paper to communicate with staff, Resident 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.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 32 085050 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0685 1/15/25 9:10 AM - The Surveyor communicated with Resident R101 using pen and paper. Resident R101 wrote that she was not offered any type of communication tools and denied refusal of hearing aids or medical appointments. Level of Harm - Minimal harm or potential for actual harm Resident R101's room lacked evidence of any type of communication devices.

Residents Affected - Few 1/17/25 11:10 AM - During an interview Resident R4 (UM) stated, [Resident R101] was offered hearing aids but she refused.

She would say she wants them but refuses when offered.

1/21/25 8:07 AM - Resident 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 [Resident 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).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 32 085050 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm 48409

Residents Affected - Few Based on record review, observation and interview, it was determined that for two (Resident R73 and Resident R66) out of three residents reviewed for bowel and bladder, the facility failed to provide appropriate treament and services to achieve or maintain as much nomal bladder function as possible. For Resident R73, the facility failed to ensure that Resident R73's urinary catheter care was monitored in a manner to prevent infection. For Resident R66, the facility failed to maintain or restore continence. Findings include:

1. Review of Resident R73's clinical record revealed:

2/20/22 - Resident R73 was admitted to the facility with diagnoses including obstructive and reflux uropathy (blockage

in the tubes that carry urine to the bladder), and retention of urine.

9/24/23 - Resident R73's clinical records documented, .Catheter Care q [every] shift.

10/26/23 - Resident R73's urinary care plan documented, [Resident R73] has an indwelling catheter . The interventions included, .Position catheter bag and tubing below the level of the bladder . Resident R73's Kardex (electronic document for the residents' care) documented, Position catheter bag and tubing below the level of the bladder.

1/9/25 - Resident R73's annual MDS documented a BIMS score of 13, indicating a cognitively intact status.

1/13/25 10:30 AM - Resident R73 was observed sitting in the wheelchair in his room. The urinary collection bag was hanging above the bladder, below the left arm rest of the wheelchair.

1/13/25 12:00 PM - Resident R73 was observed sitting in the wheelchair in the dining room eating lunch. The urinary collection bag was hanging above the bladder, below the left arm rest of the wheelchair.

1/13/25 12:45 PM - Resident R73 was observed sitting the wheelchair in the dining room eating lunch. The urinary collection bag was hanging above the bladder, below the left arm rest of the wheelchair.

1/13/25 1:00 PM - Findings were confirmed with E8 (UM.)

40264

2. A review of Resident R66's clinical records revealed the following:

10/19/23 - Resident R66 was admitted to the facility.

11/1/23 - Resident R66 was care planned for the potential for falls related to .incontinence .with interventions including education on call bell use and calling for help prior to attempting transfer .(12/12/23) and keeping pathway to

the bathroom clear and clutter free (12/11/23).

11/1/23 - Resident R66 was care planned for bladder incontinence with interventions including on toileting program as ordered (1/30/24).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 32 085050 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 1/25/24 - Resident R66's quarterly MDS revealed that Resident R66's cognition was moderately impaired and was occasionally incontinent of urine. Level of Harm - Minimal harm or potential for actual harm 4/25/24 - Resident R66's quarterly MDS revealed that Resident R66 had intact cognition and was occasionally incontinent of urine. Residents Affected - Few 7/23/24 - Resident R66's quarterly MDS revealed that Resident R66's cognition was moderately impaired and was occasionally incontinent (loss of control of bladder) of urine.

1/17/25 - A review of Resident R66's fall incident reports from January 2024 through December 2024 revealed the following:

- 3/2/24 6:30 AM - Patient found sitting on floor next to her bed .states she was trying to go to the bathroom - just toileted at 5:00 AM

- 5/8/24 12:12 AM - Patient found sitting on the floor next to her bed and stated I was going to the bathroom

- 7/2/24 11:30 AM - Patient found lying prone on the floor in her room - bed to floor .patient toileted and assisted back to bed .

- 8/16/24 1:29 AM - Patient found sitting on the floor next to the toilet in her bathroom - back leaning against

the toilet. Last toileted 12:00 AM. toilet after fall.

1/17/25 - A review of Fall Risk Evaluations from January 2023 through January 2025 revealed that Resident R66 needed assistance with toileting.

1/17/25 3:06 PM - During an interview E24 (CNA) stated that, [Resident R66] is a limited assist with toilet, has fallen a lot. She is continent of bladder and she would ask me to take her to the bathroom. She tells me when she wants me to take her to the bathroom.

1/21/25 9:54 AM - In an interview E23 (LPN) stated that [Resident R66] is mostly continent and she transfers herself to

the bathroom. We toilet her .sometimes every hour but she also lets us know if she wants to use the bathroom.

1/21/25 2:35 PM - During an interview, E2 (DON) confirmed that Resident R66's person centered toileting program was not revised. E2 presented to the surveyor a copy of Resident R66's incontinence care plan with interventions reviewed and revised on 1/17/25.

The facility failed to ensure Resident R66's person centered care plan interventions and a personalized toileting program were reviewed to address Resident R66's falls related to Resident 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).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 32 085050 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health.

Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47621

Residents Affected - Few Based on record review, observation and interview, it was determined that for two (Resident R97 and Resident R114) out of two residents reviewed for hydration, the facility failed to offer Resident R97 sufficient fluid intake in an accessible manner for her to maintain proper hydration. For Resident R114, the facility failed to ensure that Resident R114 received sufficient fluids to maintain proper hydration or provide additional interventions when Resident R114's oral intake significantly dropped. This failure resulted in harm with Resident R114 being transferred to the hospital on [DATE REDACTED] with a BUN of 100. Findings include:

The BUN (blood urea nitrogen) lab measures the amount of urea nitrogen in the blood. The BUN is directly related to the metabolic function of the liver and the excretory function of the kidney . BUN levels also may vary according to the state of hydration, with increased levels seen in dehydration and decreased levels seen

in overhydration. Mosby's Diagnostic and Laboratory Test Reference 2023

1. Review of Resident R114's clinical record revealed:

[DATE REDACTED] - Resident R114 was admitted to the facility with diagnoses including but were not limited to, dementia and stroke with resultant difficulty swallowing and language/speech deficits.

[DATE REDACTED] - Resident R114 was care planned for several problems including: has nutritional problem d/t (due to) . hx (history) need for feeding assistance, advanced age, .poor intake .Interventions for this problem included: . Monitor intake and record q (every) meal .provide assistance cueing meals as needed .

[DATE REDACTED] - Resident R114's care plan was updated with several additional problems including: .(1) has the potential for pressure ulcers, decreeased functional mobility .Interventions for this problem included : .encourage adequate nutrition/hydration . (2) has an ADL (activities of daily living) self- care performance deficit r/t (related to) weakness . Interventions for this problem included: . Eating- [Resident R114] is supervision of one person with feeding .

[DATE REDACTED] - E33 (dietician) documented in Resident R114's EMR, . [Facility] Nutrition Risk Assessment . Estimated fluids - ml (milliliter) -1200 - 1440 . Feeding status - Needs some assistance with meal set up or eating . Assessment - .[Resident R114] is able to feed herself after set up with some cueing . [Resident R114] meets criteria for malnutrition d/t (due to) dementia and variable intake .

[DATE REDACTED] - E27 (MD) ordered in Resident R114's EMR, .Med Pass (medication pass) three times a day 120 ml (additional water) .

This order added 360 mls of additional water that Resident R114 consumed each day.

[DATE REDACTED] - E34 (NP) documented in Resident R114's EMR a follow up progress note, .History of present illness: Pt (patient) appears clinically stable . Labs [DATE REDACTED] . Na (sodium) 141 mmol (millimole)/L (liter) (normal range , d+[DATE REDACTED]) . BUN 20.0 mg (milligram) /dL (deciLiter) (normal range 7XXX,d+[DATE REDACTED].0), creatinine 0.70 mg/dL (normal range 0.52 - 1.04) . Plan: weight stable: appetite variable but mostly acceptable . Continue Remeron . and encourage fluids .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 32 085050 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Resident R114's BUN at the time of this encounter was elevated at 20.0, which was reflective of Resident R114 being intravascularly dry or dehydrated. Level of Harm - Actual harm Of note, this note was not signed by the provider until [DATE REDACTED], which was five and a half months after the Residents Affected - Few encounter. The notes are only available to be read in the resident's EMR after they are signed off by the provider so this note was not available to be read until [DATE REDACTED].

[DATE REDACTED] - E22 (NP) reviewed Resident R114's labs, which documented a sodium level of 141, a BUN of 18 and a creatinine level of 0.90.

The BUN was slightly elevated at 18, where the normal range was 7.0 to 17.0.

The daily totals of Resident R114's oral intake was:

[DATE REDACTED] - 1560 mls, ,d+[DATE REDACTED]% consumption of meals for 2 out of 3 meals, dinner was 0 - 25% consumed,

[DATE REDACTED] - 1440 mls, ,d+[DATE REDACTED]% consumption of meals for 2 out of 3 meals, dinner was 0 - 25% consumed,

[DATE REDACTED] - 1320 mls, ,d+[DATE REDACTED]% consumption of meals for 2 out of 3 meals, dinner was 76 -100% consumed,

[DATE REDACTED] - 1320 mls, 26- 50% consumption of 2 out of 3 meals, dinner was 76 - 100% consumed.

[DATE REDACTED] - E35 (RN supervisor) documented in Resident R114's EMR, [Resident R114] is asymptomatic. Roommate with positive results [COVID]. Resident with room change to [room number] and contact/droplet isolation precautions initiated per protocol .

[DATE REDACTED] - 1380 mls, 26 - 50% consumption of breakfast, lunch and dinner were ,d+[DATE REDACTED]% consumed,

[DATE REDACTED] - 1080 mls, 0 - 25% consumption of breakfast and lunch, dinner was ,d+[DATE REDACTED]% consumed. CNA documented under ADL - Eating Self performance task that the Activity (eating) did not occur for lunch.

[DATE REDACTED] - 960 mls, 0 - 25 % consumption of all 3 meals,

[DATE REDACTED] - 880 mls, 0 - 25 % consumption of breakfast and lunch, dinner was ,d+[DATE REDACTED]% consumed. CNA documented under ADL - Eating Self performance task that the Activity (eating) did not occur for lunch.

[DATE REDACTED] - 1080 mls, 0 - 25 % consumption for all 3 meals. CNA documented under ADL - Eating Self performance task that the Activity (eating) did not occur for breakfast.

[DATE REDACTED] - 780 mls, 0 - 25 % consumption for breakfast, lunch and dinner were ,d+[DATE REDACTED]% consumed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 32 085050 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Of note, Resident R114's oral intake dramatically dropped after she was placed on isolation precautions for a COVID exposure on [DATE REDACTED]. Resident R114's oral intake for the four days prior to the isolation precautions all fell within Level of Harm - Actual harm Resident R114's normal oral intake range. For the seven days that Resident R114 was on isolation precautions prior to her transfer tot he hospital, on six of those days Resident R114's oral intake was documented to be significantly lower Residents Affected - Few then normal.

Additionally from [DATE REDACTED] to [DATE REDACTED], out of the twenty meals offered during these seven days, Resident R114 was documented as not eating an entire meal five times. Resident R114 failed to eat twenty-five percent of her meals

during this period. The facility failed to ensure Resident R114 met her stated hydration goals by supervising, cueing and monitoring Resident R114's intake at meals. Resident R114's EMR lacked evidence that the facility notified the providers of Resident R114's decrease in oral intake.

[DATE REDACTED] 6:17 AM- E22 gave a verbal telephone order entered into Resident R114's EMR, CBC (complete blood count) CMP (complete metabolic panel) one time only for increase in lethargy for 1 day.

[DATE REDACTED] 6:23 AM - E36 (LPN) documented in Resident R114's EMR progress note, Noted with increase lethargy. Hydration unsuccessful. New order for CBC, CMP .

Until this [DATE REDACTED] note, despite five days (,d+[DATE REDACTED] to [DATE REDACTED]) of Resident R114 poor oral intake, the facility lacked evidence that this decrease in Resident R114's oral intake was acknowledged by the staff and/or reported to the providers.

[DATE REDACTED]- 300 mls, 0 - 25 % consumption of breakfast and lunch prior to transfer to the hospital. CNA documented under ADL - Eating Self performance task that the Activity (eating) did not occur for both breakfast and lunch.

[DATE REDACTED] 12:58 PM - Per the [county paramedic's] Prehospital Care Report, Resident R114 was transferred to the hospital for an altered mental status . patient is noted to be in Atrial fibrillation at a rate of 170 bpm (beats per minute). Patient is also tachypnic (sic) (rapid breathing) at a rate of about 40. Patient is an obligate mouth breather and her oral cavity is noted to be dry .

[DATE REDACTED] 2:27 PM - Resident R114's facility lab results documented a sodium of 158 mmol/dL (normal range , d+[DATE REDACTED]), creatinine 1.80 mg/dL (normal range 0.52- 1.04). There was no reported BUN value on this lab report.

[DATE REDACTED] 2:01 PM - [Hospital] laboratory report documented Resident R97's admission/emergency room labwork with a BUN result of 101mg/dL, with this lab's normal range as 8- 22 mg/dL.

From [DATE REDACTED] to [DATE REDACTED], Resident R114's BUN elevated from 18 ([DATE REDACTED] lab work) to 100 ([DATE REDACTED] hospital lab work).

[DATE REDACTED] 00:25 AM - C2's [hospital] history and physical documented in Resident R114's hospital EMR, . [Resident R114]'s lab work was significant for sodium of 157 and a creatinine of 2.21 from a baseline of 0.9, and a BUN of 101 . Assessment/Plan: Sepsis, unspecified organism- unclear source but patient has mulit-organ failure including her kidneys, her liver as well as evidence of new onset A-fib .

[DATE REDACTED] - Resident R114 expired at [hospital] on hospice service.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 32 085050 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 [DATE REDACTED] 11:45 AM - Review of Resident R114's EMR progress notes lacked evidence of any notation regarding Resident R114's decreased oral fluid intake or any notification of Resident R114's providers regarding her decreased oral intake until Level of Harm - Actual harm [DATE REDACTED] 6:23 AM progress note in which E36 (LPN) documented, .Hydration unsuccessful .

Residents Affected - Few [DATE REDACTED] 2:33 PM - During an interview, E4 (RN/unit manager) stated, It was not unusual for [Resident R114] to ignore you if she did not want to deal with you. She played possum. She often refused her meds. Her vital signs were normal but as the day [[DATE REDACTED]] progressed she became tachycardic and her breathing changed so we sent her out. She had had labs drawn that morning but they were not back when we sent her out.

[DATE REDACTED] 8:16 AM - During an interview, E36 (LPN) stated, . [Resident R114] was her normal self. (neurologically) I was trying to give her water to drink because I was worried about dehydration.

Cross refer

F-F810.

2. Review of Resident R97's clinical record revealed:

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

[DATE REDACTED] 9:56 AM - E13 (dietician) documented on the [facility] Nutrition Risk Assessment in Resident R97's EMR, . Estimated fluids- ml (milliliter) - 1500 - 1800 ml (,d+[DATE REDACTED] 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 REDACTED] 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 REDACTED] 1:00 PM - E27 (MD) ordered in Resident 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 Resident R97's documented oral intake during this time period.

[DATE REDACTED] - Resident 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 .[Resident 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 Resident R97's fluid intake were:

[DATE REDACTED] - 1440 mls

[DATE REDACTED] - 1200 mls.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 32 085050 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 [DATE REDACTED] - 1680 mls.

Level of Harm - Actual harm [DATE REDACTED] - 1080 mls.

Residents Affected - Few [DATE REDACTED] - 1800 mls.

[DATE REDACTED] - 1410 mls.

[DATE REDACTED] - 1800 mls.

[DATE REDACTED] - 1760 mls.

[DATE REDACTED] - 1560 mls.

[DATE REDACTED] 1:31 PM - Resident R97's lab revealed a BUN (blood urea nitrogen) level of 61.0 mg(milligrams)/ dL (deciliter).

The BUN normal reference level for this lab was 7.0 to 17.0 mg/dL so Resident R97's BUN result of 61.0 was elevated and reflective of a state of dehydration.

[DATE REDACTED] 2:32 PM - E29 (NP) documented in Resident R97's EMR reviewing these lab results. Resident R97's EMR lacked evidence of E29 addressing Resident R97's elevated BUN in either a progress note or with any new orders.

[DATE REDACTED] - 1920 mls.

[DATE REDACTED] - 1680 mls.

[DATE REDACTED] - 1320 mls.

[DATE REDACTED] 4:06 PM- The surveyor observed Resident R97's bedside table with a full, white styrofoam cup with a straw and ice water in it.

[DATE REDACTED] 10:30 AM - The surveyor observed Resident R97's bedside table with a full, white styrofoam cup with a straw and ice water in it

[DATE REDACTED] - 1310 mls.

[DATE REDACTED] - 1430 mls

Resident R97's stated hydration goals were 1500 - 1800 mls per day. From [DATE REDACTED] to [DATE REDACTED], there were seven out of fourteen days, where it was documented that Resident R97's oral fluid intake was less than her documented minimum fluid goal. The facility failed to ensure Resident R97 met her stated hydration goal by failing to provide bedside water

in a Kennedyadaptive cup that Resident R97 could independently consume, failing to assist and cue Resident R97 to drink her bedside water, and failing to address Resident R97's decreased oral fluid intake with Resident R97's provider.

From [DATE REDACTED] to [DATE REDACTED], the CNA staff documented in Resident R97's CNA tasks list report under Eating Self-performance- How resident eats and drinks, regardless of skill? that for twenty-nine times of the thirty-nine recorded entries, Resident R97 was Total dependence - full staff performance with regards to this task.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 32 085050 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 [DATE REDACTED] 10:30 AM - Review of Resident R97's EMR progress notes lacked evidence of any notation regarding Resident R97's decreased oral fluid intake or any notification of Resident R97's providers regarding her decreased oral intake. Level of Harm - Actual harm [DATE REDACTED] 1:01 PM - During an interview, E30 (LPN) stated, [Resident R97] gets an adaptive cup on her meal trays. But I Residents Affected - Few have never seen one on her bedside tray during non-mealtimes. She usually gets her bedside water in a white styrofoam cup .

[DATE REDACTED] 1:07 PM - During an Interview, E32 (OT) stated, [Resident R97] is ordered specialized dining utensils. it is part of the diet order . She [Resident R97] is ordered a Kennedy cup because the handle allows her to pick the cup up independently.

[DATE REDACTED] 1:35 PM - Review of Resident R97's orders and CNA tasks list report lacked evidence of an order related to Resident R97 utilizing a [NAME] adaptive cup outside of her meal tray.

[DATE REDACTED] 2:45 PM - During an interview, E24 (CNA) stated, When we pass the [bedside] water, we use the white styrofoam cups for [Resident 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.

[DATE REDACTED] 3:28 PM - E15 (CNO) presented the surveyor with a copy of a new order for Resident R97 stating offer water

in Kennedy cup q (every) shift. E15 also provided a copy of Resident R97's CNA tasks list report with a new task Provide Q (every) shift water in Kennedy cup.

[DATE REDACTED] 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).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 32 085050 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Level of Harm - Minimal harm or 47621 potential for actual harm Based on record review and interview, it was determined that for one (Resident R91) out of twenty-seven residents Residents Affected - Few reviewed for physician services, the facility failed to ensure that Resident R91's required visits were coordinated and alternated between the physician and the NP. Findings include:

Review of Resident R91's clinical record revealed:

9/18/23 - Resident R91 was admitted to the facility with diagnoses including, but were not limited to, dementia and anxiety disorder.

12/21/23 - E27 (MD) assessed and wrote a progress note for Resident R91.

5/20/24 - E28 (NP) assessed and wrote a progress note for Resident R91.

Resident R91 went 151 days without being seen by a provider at the facility. This reflected Resident R91 missing two required 60 day visits by a provider.

6/20/24 - E29 (NP) assessed and wrote a progress note for Resident R91.

Based on the 5/20/24 encounter was provided by a nurse practitioner, Resident R91 was required to be seen by the physician by 7/20/24. The facility was not able to provide evidence of Resident R91 being seen by a physician on or around 7/20/24.

7/31/24 - E29 (NP) assessed and wrote a progress note for Resident R91.

8/7/24 - E29 (NP) assessed and wrote a progress note for Resident R91.

8/8/24 - E27 (MD) assessed and wrote a progress note for Resident R91.

Resident R91 went 231 days between physician visits.

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).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 32 085050 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm 40264

Residents Affected - Few Based on record review and interview, it was determined that for two (Resident R78 and Resident R90) out of five residents reviewed for medication review, the facility failed to ensure the provider documented that irregularities were reviewed. In addition, the facility failed to ensure the Drug Regimen Review policy included all of the time frame requirements. Findings include:

1. Review of Resident R78's clinical record revealed:

a. 2/25/24 - Review of Resident R78's drug regimen reviews found the pharmacist identified an irregularity and asked if a repeat TSH (Thyroid Stimulating Hormone) test be of benefit at this time since Resident R78's TSH drawn on 1/10/23 was high at 12.911 but improved from prior level on 12/11/23. There was no evidence that the physician reviewed this pharmacy concern.

1/16/25 10:00 AM - In an interview, E2 (DON) confirmed that the 2/25/24 pharmacy recommendation was not signed off by the physician and that a signed copy of the facility's response could not be found on Resident R78's medical records.

b. 1/16/25 8:42 AM - A review of the facility's policy titled, Consultant Pharmacist Chart Review Reports and Records, revealed a lack of information of the facility's time frame to respond to the pharmacy recommendations based on identified irregularities.

1/16/25 9:49 AM - In an interview, E15 (CNO) confirmed that facility's time frame to respond to the pharmacy recommendations based on identified irregularities was not identified in the current policy and that the policy will be reviewed and revised.

1/21/25 2:40 PM - Findings were discussed with E1 (NHA) and E2.

32545

2. Resident R90's clinical record revealed:

10/21/24 - Resident R90 was admitted to the facility.

10/21/24 - The Consultant Pharmacist Admission Review recommended that Resident R90 have an apical pulse parameter with the administration of Amiodarone medication.

The undated handwritten response on the 10/21/24 pharmacist recommendation was signed by E22 (NP) and documented, (Will refer to cardiology).

Review of Resident R90's clinical record lacked evidence that this recommendation for cardiology were carried out and

the documented action that was taken.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 32 085050 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 1/17/24 at 8:55 AM - During an interview, E6 (UM/RN) confirmed that the recommendation was signed but not dated by E22 (NP). E6 reviewed Resident R90's cardiology consultant notes from 10/22/24 and 10/29/24 and Level of Harm - Minimal harm or confirmed that this pharmacy recommendation was not addressed in either of those notes. potential for actual harm 1/22/25 at 3:04 PM - Finding was reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), Residents Affected - Few E8 (Staff Educator), E14 (COO) and E15 (CNO).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 32 085050 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0773 Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Level of Harm - Minimal harm or potential for actual harm 32545

Residents Affected - Few Based on record review and interview, it was determined that for one (Resident R90) out of five residents reviewed for unnecessary medications, the facility failed to ensure that laboratory services were obtained only when ordered by a provider. Findings include:

Resident R90's clinical record revealed:

12/28/24 - Resident R90 had a blood draw performed for three labs (CBC, CMP, Mg).

Review of Resident R90's clinical record lacked evidence of a physician order for the 12/28/24 labs.

The facility failed to obtain laboratory services only when ordered by a provider.

1/22/24 at 1:00 PM - Finding was reviewed with E2 (DON) and E15 (CNO).

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).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 32 085050 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47621 potential for actual harm Based on record review, observation and interview, it was determined that for one (Resident R97) out of four residents Residents Affected - Few reviewed for ADLs (activities of daily living), the facility failed to supply Resident R97's bedside water in a [NAME] adaptive cup. Findings include:

Facility Adaptive Feeding Equipment policy: It is the policy of [facility] that residents requiring adaptive feeding equipment will receive such equipment.

Cross refer