Cadia Rehabilitation Silverside

In the surveyor’s words

From the most serious findings on record at Cadia Rehabilitation Silverside, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Aug 11, 2026

  Based on interview, observation, and review of clinical record, surveillance video and other records as indicated, it was determined that for one (R1) out of three residents reviewed for respiratory care, the facility failed to ensure that nursing staff provided appropriate care and services to R1, a resident with a diagnosis of congestive heart failure who had an acute respiratory change of condition that started after dinner on 8/2/26. While facility staff reported to the assigned nurse multiple times that R1 was coughing, had increased mucus but could not cough it up, and had trouble breathing, the nurse failed to recognize and act upon R1's acute respiratory change of condition by auscultating R1's lungs during her assessment, or to attempt to suction his airway for mucus/oral… […]

• Immediate jeopardy, isolatedF609Mar 27, 2025

  Based on interviews, record review, and policy review, the facility failed to ensure allegations of abuse were reported for one of three residents (Resident (R) 80) reviewed for abuse. The facility did not report to the State Agency alleged staff-to-resident abuse within the required time frame. Facility staff did not report R80's allegation of employee-to-resident abuse to the Administrator. This failure to report the allegation in a timely manner allowed the accused staff member to continue working in the facility with other residents. The Immediate Jeopardy began on 07/07/24, undetermined time between 12:00 PM and 3:00 PM. On 03/13/25 at 7:42 PM, the Administrator was notified of Immediate Jeopardy (IJ) Past Non-Compliance (PNC) in the area of Resident Abuse at F609. […]

• Actual harm, isolatedF689Apr 27, 2026

  Based on observation, interview, record review, and review of other documentation as indicated, it was determined that for three (R12, R63, and R76) out of three residents sampled for accidents, the facility failed to ensure that the residents received adequate assistance and supervision to prevent accidents to the extent possible. R12, a completely dependent resident, sustained a fall from the bed to the floor while a staff member was providing care and sustained a right ankle fracture. R63, a resident who required extensive assistance for transfers, sustained L2 and L3 fractures during a transfer from the shower bed to the bed and was sent emergently to the hospital. […]

• No harm, potential for more than minimal, widespreadF880Mar 27, 2025

  25232 36190 Based on observation, interview and policy review, the facility failed to follow Transmission Based Precautions, use proper hand hygiene, and change gloves during incontinent care. These breaches in infection control could cause a spread in disease and affect all the residents. Findings include: Review of the facility policy titled Infection Prevention and Control Program Policy, revised 04/14/21, provided by the facility revealed 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) . […]

• No harm, potential for more than minimal, patternF585Mar 27, 2025

  36190 Based on observation, interview, record review, and policy review, the facility failed to inform seven of seven residents in the resident council about the facility's grievance policy, the grievance official responsible for overseeing the grievance process was with their contact information and resolve grievances for three (Residents (R)158, R34, and R59) of three residents reviewed for grievances. This failure could prevent residents from addressing concerns and seeking resolution, leading to frustration and potentially impacting their well-being. […]