Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Broadway Healthcare Center during CMS and state inspections, most recent first.
A resident with a high fall risk was left unattended in a high back wheelchair, resulting in a fall and significant injuries, including facial fractures. The resident's care plan and therapy evaluations indicated a need for total assistance with mobility, but the facility failed to provide adequate supervision, leading to the incident.
The facility failed to maintain a clean and sanitary food service area, with issues including an unclean juice machine, improperly sealed food containers, stained coffee mugs, and damaged food trays. These deficiencies were confirmed by the Dietary Manager and a dietary assistant, highlighting the risk of cross-contamination and illness.
A facility staff member failed to protect a resident's confidential information by leaving a computer screen open with the resident's medical details visible to others. The resident had serious health conditions, and the incident occurred in a public area, potentially exposing the information to unauthorized individuals. Despite staff training on HIPAA compliance, the screen was left unattended, violating privacy policies.
A facility failed to accurately document a resident's schizophrenia diagnosis in the MDS, despite the resident being treated with Seroquel for this condition. The omission was confirmed by staff, including the DON, who acknowledged that the MDS should reflect the resident's current status to aid in care planning. The MDS nurse cited a lack of comprehensive psychiatric documentation as the reason for not coding schizophrenia, even though the resident had been seen by a psychiatrist multiple times.
A resident with a stage 2 pressure ulcer, UTI, and sepsis experienced a worsening of their condition to a stage 3 ulcer due to non-compliance with care interventions. The facility failed to update the care plan to reflect the resident's refusal to be repositioned or sit in a cushioned wheelchair until after the ulcer worsened. Despite staff awareness of the non-compliance, the care plan was not revised in a timely manner, contrary to facility policy.
A resident with serious health conditions was improperly administered oxygen by a CNA instead of a licensed nurse, contrary to facility policy. The CNA placed a nasal cannula and turned on the oxygen concentrator without consulting a nurse, risking incorrect care. Interviews confirmed that only licensed nurses should administer oxygen, as it is considered a medication.
A resident with serious medical conditions was not provided a communication device in their preferred language, hindering effective communication with staff. Despite the facility's policy requiring trained interpreters, staff failed to use available translation services, leading to a situation where the resident's complaint of shortness of breath was not immediately addressed. The Director of Nursing acknowledged the failure to adhere to language access policies, resulting in a deficiency.
A resident dependent on staff for ADLs was found with long, jagged fingernails, leading to skin injuries due to scratching. Despite the resident's care plan indicating the need for nail maintenance, the facility failed to provide adequate grooming services. Observations and interviews confirmed the deficiency, highlighting a lapse in adhering to facility policies on personal hygiene.
A facility failed to administer oxygen to a resident as per physician's orders, despite the resident's medical conditions requiring continuous oxygen. The resident, who had diagnoses including congestive heart failure and acute respiratory failure, was found without oxygen and experiencing shortness of breath. The deficiency was confirmed through observations and interviews, revealing a lack of adherence to the facility's oxygen administration policy.
A facility failed to accurately measure the salt content in a meal for a resident on a renal diet, risking excessive sodium intake. The resident, with end-stage renal disease, received chicken gravy prepared without precise measurement, contrary to facility policy. The DON confirmed the gravy was salty, and the Dietary Manager emphasized the need for accurate measurements as per dietary recommendations.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a pressure ulcer, contrary to its policy. The resident was not placed on EBP upon admission, and there was no signage or PPE outside the room. Staff misunderstood EBP requirements, believing it was only necessary for wounds with drainage, leading to non-compliance with infection control policy.
The facility failed to post daily staffing information in a visible and prominent location, as required by policy. Observations revealed that the staffing data was placed behind a door, making it inaccessible to residents, staff, and visitors. The DON was unaware of this practice, which contradicted the facility's policy to post staffing data in a clear and readable format.
The facility was found to have five residents in Room O, exceeding the maximum of four residents per room. The administrator confirmed this arrangement and had requested a waiver, arguing that it did not impact resident health and safety. The waiver indicated sufficient space for care and mobility, with room assignments reviewed for appropriateness.
The facility did not meet the required 80 square feet per resident in 14 of 24 rooms, with space ranging from 77.70 to 79.66 square feet per resident. Despite this, residents did not complain, and there was enough room for care and mobility. The Administrator acknowledged the deficiency and requested a waiver, stating that the space was adequate for care and did not affect residents' health and safety.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision for a resident, identified as Resident 11, who was assessed as being at risk for falls. On the morning of 11/20/2024, Resident 11 was left unattended in a high back wheelchair by a Certified Nurse Assistant (CNA 5) who turned away to retrieve linen. During this brief period, Resident 11 fell forward from the wheelchair, resulting in a fall that caused significant injuries, including a left eyebrow laceration, blunt head injury, and multiple facial fractures. Resident 11 had a documented history of cognitive and physical impairments, including dementia, abnormal posture, and schizophrenia, which contributed to their fall risk. The resident's care plan, dated 8/24/2024, highlighted the potential for falls and included interventions such as not leaving the resident unattended in the shower room. However, it did not explicitly mention supervision requirements when the resident was in a wheelchair. The resident's physical and occupational therapy evaluations indicated a need for total assistance with mobility and wheelchair management, underscoring the resident's dependency on staff for safety. Interviews with facility staff, including the Licensed Vocational Nurse (LVN 1), Registered Nurse (RN 1), and the Director of Nursing (DON), revealed that the resident's high back wheelchair could be tilted and reclined to prevent forward falls. However, it was unclear whether the wheelchair was properly adjusted at the time of the incident. The facility's policies on managing falls and supporting activities of daily living emphasized the need for tailored interventions to prevent falls, but these were not effectively implemented in Resident 11's case, leading to the fall and subsequent injuries.
Deficiencies in Food Service Area Sanitation
Penalty
Summary
The facility failed to maintain the food service area in a clean and sanitary manner, as observed during a survey. The juice machine was found with dried coffee drippings and a connecting tube with sticky brown and black gunk. Additionally, a container of ground ginger was observed with an improperly sealed lid, and coffee mugs were noted to have stains. Furthermore, food trays were found to be in poor condition, with cracks, chipping, and peeling laminate, which could potentially expose residents to pathogens. Interviews with the Dietary Manager and a dietary assistant confirmed these observations. The Dietary Manager acknowledged the unclean state of the juice machine and the improperly sealed food containers, emphasizing the risk of cross-contamination and illness. The dietary assistant also noted that cracked food trays could harbor bacteria, leading to cross-contamination. The facility's policies and procedures, revised in November 2022, require that the food service area be maintained in a clean and sanitary manner, with all equipment and utensils kept in good repair and free from damage.
Failure to Protect Resident's Confidential Information
Penalty
Summary
The facility staff failed to protect the confidential personal information of a resident by not closing the computer screen after accessing the resident's medical information at the nursing station. This incident occurred in the presence of other staff, residents, and visitors, potentially exposing the resident's medical records to unauthorized individuals. The resident involved had been admitted with multiple serious health conditions, including acute on chronic combined systolic and diastolic congestive heart failure, acute respiratory failure with hypoxia, and pneumonia, among others. During an observation, a Licensed Vocational Nurse (LVN) was seen leaving the computer screen open and unattended after reviewing the resident's medical information. A Certified Nursing Assistant (CNA) confirmed the screen was left open, and anyone passing by could view the resident's private information. Interviews with the Director of Nursing (DON) and the Director of Staff Development (DSD) revealed that staff had been educated on HIPAA compliance, which includes not leaving computer screens with resident information open. The facility's policy emphasizes maintaining the confidentiality of each resident's personal and protected health information.
Failure to Accurately Document Schizophrenia Diagnosis in MDS
Penalty
Summary
The facility failed to ensure an accurate assessment of the Minimum Data Set (MDS) for a resident by not including the diagnosis of schizophrenia. The resident, who had a history of schizophrenia, was being treated with Seroquel for this condition. Despite this, the MDS did not reflect schizophrenia as an active diagnosis, which was confirmed by multiple staff members, including a Registered Nurse and the Director of Nursing. The omission was noted during a review of the resident's medical records, which included documentation of schizophrenia in the General Acute Care Hospital Emergency department history and physical, as well as an order for Seroquel specifically for schizophrenia. The MDS nurse stated that schizophrenia could not be coded in the MDS due to a lack of comprehensive psychiatric documentation, despite the resident having been seen by a psychiatrist multiple times. The Director of Nursing acknowledged that the MDS should reflect the resident's current status, including active diagnoses, to assist in developing an appropriate care plan. The facility's policy and procedure indicated that the resident assessment coordinator is responsible for ensuring accurate and timely assessments, which should consistently reflect information in progress notes and care plans.
Failure to Revise Care Plan for Non-Compliant Resident with Pressure Ulcer
Penalty
Summary
The facility failed to revise the care plan for a resident with a stage 2 pressure ulcer, which progressed to a stage 3 ulcer due to non-compliance with care interventions. The resident, who was admitted with a stage 2 pressure ulcer, urinary tract infection, and sepsis, required assistance with bed mobility and activities of daily living. Despite the resident's refusal to be repositioned or to sit in a cushioned wheelchair, the care plan was not updated to reflect these compliance issues until after the ulcer worsened. The interdisciplinary team conducted several wound management assessments, noting the resident's non-compliance and the need for repositioning every two hours. However, the care plan was not revised to address the resident's refusal to comply with these interventions until the pressure ulcer had already progressed to a stage 3. Staff interviews revealed that the resident's non-compliance was known but not documented in the care plan in a timely manner, and interventions such as offering soda to encourage cooperation were not included. The facility's policy requires care plans to be revised when there is a significant change in the resident's condition or when desired outcomes are not met. Despite this, the care plan was only updated after the ulcer worsened, highlighting a failure to adhere to the policy. The resident's refusal to participate in care was not documented as required, contributing to the deficiency in care planning and potentially impacting the resident's health outcomes.
Improper Oxygen Administration by CNA
Penalty
Summary
The facility failed to ensure professional standards of quality for administering oxygen to a resident, identified as Resident 9, by allowing a Certified Nurse Assistant (CNA) to administer oxygen instead of a licensed nurse. Resident 9, who was admitted with multiple serious health conditions including acute on chronic congestive heart failure, acute respiratory failure with hypoxia, and pneumonia, was observed without oxygen and short of breath. The CNA placed a nasal cannula on Resident 9 and turned on the oxygen concentrator to 5 liters per minute without consulting a licensed nurse, which is against the facility's policy. The incident occurred when the CNA assisted Resident 9 from a bedside commode back to bed and noticed the resident was short of breath. Despite the resident's request for oxygen, the CNA proceeded to administer it without verifying the physician's order or consulting a licensed nurse. The CNA later acknowledged that she was not aware of the specific oxygen order and admitted that it was not within her scope of practice to turn on the oxygen machine. Interviews with the Licensed Vocational Nurse (LVN), Director of Nursing (DON), and Director of Staffing Development (DSD) confirmed that CNAs are not authorized to administer oxygen, as it is considered a medication that should only be administered by licensed nurses. The facility's policy and procedure documents also support this, indicating that oxygen administration requires assessment and monitoring by a licensed nurse to ensure the correct dosage and prevent potential harm to the resident.
Failure to Provide Communication Device in Preferred Language
Penalty
Summary
The facility failed to provide a communication device in the preferred language of a resident, identified as Resident 9, which hindered effective communication with the staff. Resident 9 was admitted with several serious medical conditions, including acute on chronic combined systolic and diastolic congestive heart failure, acute respiratory failure with hypoxia, acute and chronic pulmonary edema, pleural effusion, and pneumonia. Despite having the capacity to understand and make decisions, Resident 9's preferred language was not accommodated, as indicated in the Minimum Data Set (MDS) and care plan. During observations, it was noted that Resident 9 did not have a communication or picture board at the bedside. On one occasion, a Licensed Vocational Nurse (LVN1) attempted to communicate with Resident 9 in a language the resident did not understand, leading to a failure in recognizing the resident's complaint of shortness of breath. The Director of Nursing (DON) acknowledged that it was unacceptable for LVN1 to leave the resident alone while experiencing shortness of breath and confirmed that the facility had a phone service for translation that should have been used. The facility's policy on translation and interpretation services was not adhered to, as it requires trained interpreters and prohibits reliance on family members for interpretation unless explicitly requested by the resident. The DON confirmed discrepancies in the resident's language preferences as recorded in the MDS and face sheet. The lack of appropriate communication tools and adherence to language access policies resulted in a deficiency that compromised Resident 9's ability to communicate effectively with the staff.
Failure to Provide Adequate Grooming Services
Penalty
Summary
The facility failed to provide adequate grooming services for a resident who was dependent on staff for activities of daily living (ADLs). The resident, who was non-verbal and had severely impaired cognitive skills, was observed with long, jagged fingernails. This condition was noted during an observation by a certified nursing assistant and a registered nurse supervisor, both of whom confirmed the resident's nails were rough and sharp. The resident had multiple wounds on the right leg, attributed to a habit of scratching, which was exacerbated by the condition of the nails. The resident's medical history included diagnoses of lack of coordination, sepsis, and dysphagia, and they were totally dependent on staff for personal hygiene and other ADLs. The resident's care plan, which was reviewed and revised multiple times, indicated the need for assistance with personal hygiene and specifically mentioned the necessity of keeping the resident's nails trimmed to prevent skin injuries. Despite these documented needs and interventions, the facility did not ensure the resident's nails were maintained in a safe condition. The facility's policies and procedures emphasized the importance of providing care to maintain or improve residents' ability to perform ADLs, including grooming and personal hygiene. However, the facility did not adhere to these policies, resulting in the resident having long, jagged fingernails that contributed to skin injuries. The deficiency was identified through observations, interviews, and record reviews, highlighting a failure to implement the care plan and facility policies effectively.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to provide necessary respiratory care services for Resident 9 by not administering oxygen according to the physician's orders. Resident 9, who was admitted with acute on chronic combined systolic and diastolic congestive heart failure, acute respiratory failure with hypoxia, acute and chronic pulmonary edema, pleural effusion, and pneumonia, was observed without oxygen and experiencing shortness of breath. The physician's order required continuous oxygen administration at 2 to 5 liters per minute via nasal cannula due to hypoxia related to congestive heart failure. However, during an observation, the resident was found without oxygen, and a Certified Nurse Assistant (CNA) had to ask the resident if they wanted oxygen, which was then administered at 5 liters per minute. The deficiency was further highlighted during interviews and record reviews, where it was confirmed that the resident had an order for continuous oxygen, not as needed (PRN) oxygen. The Director of Nursing acknowledged that oxygen is considered a regular medication order and that the resident was at risk of harm while complaining of shortness of breath because oxygen needed to be administered. The facility's policy and procedure for oxygen administration, which includes placing an 'Oxygen in Use' sign outside the room, was not followed, as there was no sign observed outside Resident 9's room. This failure to adhere to physician orders and facility policies placed the resident at risk for complications such as respiratory distress.
Failure to Measure Salt Content in Renal Diet
Penalty
Summary
The facility failed to accurately measure the salt content of food served to a resident on a renal diet, which is crucial for individuals with kidney disease to limit certain nutrients such as salt. The resident, who was diagnosed with end-stage renal disease and dependent on renal dialysis, was at risk of receiving more sodium than required due to this oversight. During an observation, it was noted that a staff member prepared chicken gravy for the resident without using a measuring device, instead approximating the amount by 'eyeballing' it. This practice was against the facility's policy, which requires precise measurement of ingredients to adhere to dietary recommendations. The Director of Nursing confirmed that the gravy served was salty and emphasized the importance of following exact recipe measurements for therapeutic diets. The Dietary Manager also stated that all ingredients need to be measured accurately, as per the facility's policy. A review of the resident's order summary and the facility's policy on liberal renal diets indicated that salt packages should be eliminated, highlighting the discrepancy in the preparation of the resident's meal. The facility's standardized recipe policy further reinforced the need for exact measurements for all ingredients, underscoring the deficiency in the preparation of the resident's meal.
Failure to Implement Enhanced Barrier Precautions for Resident with Wound
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a stage two pressure ulcer, which later regressed to stage three. Despite the facility's policy requiring EBP for residents with wounds, the resident was not placed on EBP upon admission. The resident's admission data tool incorrectly indicated that EBP was not warranted, and there was no EBP signage or PPE cart outside the resident's room. The Infection Preventionist Nurse and Treatment Nurse both stated that EBP was not ordered or implemented because the resident's wounds had no drainage. The Director of Nursing acknowledged that EBP should have been ordered upon the resident's admission and included in the care plan. The facility's policy outlined that EBP is necessary for high-contact activities such as dressing, bathing, and wound care, and requires signage and PPE availability. The lack of EBP implementation was due to a misunderstanding that EBP was only necessary for wounds with moderate to heavy drainage, leading to a failure to follow the facility's infection control policy.
Failure to Post Staffing Information in Visible Location
Penalty
Summary
The facility failed to ensure that staffing information, including the total number of staff and the actual hours worked, was posted in a visible and prominent place on two consecutive days, 1/21/2025 and 1/22/2025. During an observation on 1/21/2025 at 7:45 AM, no visible daily staffing information was found in the facility lobby. On 1/22/2025, during a concurrent observation and interview at 2:42 PM, RN 2 indicated that the staffing information was posted on the wall behind a door leading to resident rooms, making it not visible to residents, staff, and visitors. Further investigation on 1/22/2025 at 2:44 PM with the Director of Nursing (DON) revealed that the DON was unaware that the staffing information was being posted behind the door. The facility's policy, revised in August 2022, requires that staffing data be posted daily in a prominent location accessible to residents and visitors. The DON acknowledged the importance of posting this information visibly to ensure that residents and visitors are informed about the facility's staffing levels, which are necessary to deliver care in accordance with regulations.
Facility Exceeds Resident Capacity in Room O
Penalty
Summary
The facility failed to comply with regulations by accommodating five residents in Room O, which exceeds the maximum allowable number of four residents per room. This was observed during a survey on January 24, 2025, where all five beds in Room O were occupied. The facility's administrator confirmed the room's occupancy and stated that a waiver had been requested to allow this arrangement, arguing that it did not affect the health and safety of the residents and that there was sufficient space for staff to provide care. The room waiver, dated January 16, 2024, indicated that Room O had five beds with a total area of 511.60 square feet. The facility's waiver request, dated January 21, 2025, sought continued permission for reduced square footage per resident, provided that room assignments were reviewed during the admission process and checked frequently for appropriateness. The waiver also claimed that ample space was available for resident care and mobility, and that room rounds were conducted to ensure no unnecessary items or equipment hindered access.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to provide the minimum required 80 square feet per resident in multiple resident bedrooms for 14 out of 24 rooms, as observed during a tour. These rooms, labeled A through N, did not meet the square footage requirement, with measurements ranging from 77.70 to 79.66 square feet per resident. Despite this, residents did not express complaints about the space, and there was sufficient room for staff to provide care and for residents, including those who are wheelchair-bound, to move without difficulty. The facility's Administrator acknowledged the deficiency, stating that 14 rooms did not meet the required space per resident. The Administrator indicated that a room waiver had been requested from CMS, arguing that the space was adequate for care and did not impact residents' health and safety. The facility's Client Accommodation Analysis and room waiver letter supported this claim, noting that room assignments were reviewed for appropriateness and that there was ample space for resident care and mobility. The recertification survey confirmed that the rooms had adequate ventilation, lighting, and privacy features, with sufficient space for wheelchair access and movement.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Gabriel
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Live Oak Rehab Center | 0.6 mi | — | 30 | 1 |
| Ivy Creek Healthcare & Wellness Centre | 0.6 mi | — | 1 | 0 |
| San Gabriel Valley Medical Ctr D/p Snf | 0.6 mi | — | 3 | 0 |
| Royal Vista Care Center | 0.6 mi | — | 30 | 0 |
| Pine Grove Healthcare & Wellness Centre, Lp | 0.7 mi | — | 18 | 0 |
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