Cadia Rehabilitation Broadmeadow
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
side, and 2 persons with the Hoyer lift for transfers.11/13/25 1:30 PM - During an interview, E4 (OT) stated, [Resident R1] required 2 persons assistance to roll from side to side for the staff to wash and clean her. She was not able to help with her care.11/13/25 2:00 PM - During a telephone interview, E5 (CNA) stated, I have been
an aide for four years, but I was new to this facility. I was told that this resident [Resident R1] was on my assignment for the shift. I rolled her on her side to clean her bottom, and she rolled out of the bed on to her face. The Surveyor asked E5 if she knew where the transfer/bed mobility/rolling side to side information for the resident was located. E5 stated, I was told it was in the closet, but I was not actually shown where it was located. I saw other aides take care of her by themselves, so I thought I have to do her care by myself. No one ever told me I had to have another aide with me when I was taking care of her. The Surveyor asked E5 whether Resident R1 was able to move, hold herself to the side in the bed or assist in her ADLs, E5 stated, No, she was not able to move herself or help with anything. The staff did everything for her.11/13/24 2:20 PM - The facility 5 day follow up report submitted to the Division included, .Resident remains hospitalized at this time.
Upon return she is to be evaluated by therapy and care plan will be updated to include concave LAL and bilateral fall mats while in bed.11/14/25 10:00 AM - During a combined interview with E1 (NHA) and E2 (DON), the Surveyor asked what the facility's investigation revealed to be the root cause of Resident R1's fall. E1 stated, The aide did not position her properly in the bed and she rolled out. The Surveyor asked E1 whether
the facility had identified that the Resident R1's plan of care for two persons assistance with rolling side to side was not implemented during incontinent care. E1 stated, The resident did not have to be rolled side to side for incontinent care. The aide's statement said that she had positioned her [Resident R1] on her side for 5 minutes
before she rolled out of the bed.11/14/25 2:00 PM - During an interview, E2 provided the Surveyor with an undated document, entitled, Plan of Correction. The document included, The facility conducted a root cause analysis, and it was determined that the assigned CNA did not safely position the resident during incontinence care to avoid the resident from rolling out of bed. Ad hoc QAPI meeting was conducted facility leadership. Employee was immediately educated and suspended pending investigation. A house wide audit was conducted of all mobility care plans for residents who are assist of two. No issues were identified. All nurses and CNAs were re-inserviced on safe positioning during care and transfer status/bed mobility care plans.The facility's investigation failed to identify that Resident R1, a completely dependent resident, who was care planned for the assistance of two staff members with rolling side to side, required two persons assistance for moving and turning in bed to prevent her from rolling out of the bed during incontinence care.The facility failed to ensure that Resident R1's incontinence care was completed with the required number of staff members according to her plan of care. This failure resulted in Resident R1 falling from the bed and sustaining injuries.11/14/25 2:30 PM - Findings were reviewed with E1 (NHA) and E2 (DON) at the exit conference.
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CADIA REHABILITATION BROADMEADOW in MIDDLETOWN, DE inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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.