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 Manor Care Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities and on anticoagulant therapy experienced a significant change in condition, including altered mental status, hypotension, shortness of breath, and multiple episodes of coffee-ground emesis. Despite clear orders and care plan instructions, licensed nursing staff did not notify the physician or PA during the critical period, resulting in delayed emergency intervention. EMS was called only after the resident's condition became critical, and the resident later died at the hospital. This failure was identified as an Immediate Jeopardy deficiency.
A resident with a history of PAD, atherosclerosis, and recent stroke was readmitted from the hospital, but staff failed to include PAD in the diagnosis list, did not develop a care plan for vascular disease, and did not follow hospital recommendations for vascular assessment. Staff inconsistently monitored pedal pulses and focused on behavioral interventions for self-inflicted wounds rather than addressing underlying vascular issues. The resident's condition deteriorated, resulting in hospitalization for sepsis, gangrene, and ultimately death.
The facility failed to transmit MDS assessments to CMS within the required 14-day period for several residents, with delays ranging from 9 to 91 days. The MDS Nurse cited being overwhelmed with responsibilities as the reason for the delays, despite additional support. The Administrator and Director of Nurses acknowledged the issue, emphasizing the importance of timely submissions for accurate resident assessments and care planning.
The facility failed to follow proper sanitation and food handling practices by leaving a scoop inside a thickener container with its handle touching the contents. This was observed during a kitchen inspection, and the Dietary Supervisor confirmed that the scoop should not have been left inside, as it could lead to cross-contamination. The facility's policy requires that scoops be cleaned after each use and not left in containers.
The facility's QAPI committee failed to ensure timely transmission of MDS to CMS, affecting 11 residents. Despite hiring additional staff, the MDS Nurse was unable to submit assessments on time due to other responsibilities. The Administrator acknowledged the issue but lacked a documented plan to resolve it.
A resident with generalized anxiety disorder and muscle weakness was unable to reach the call light, which was placed on a bedside table. The resident required assistance with daily activities, and the facility's policy mandated that the call light be accessible. Both an LVN and the ADON confirmed the call light should be within reach to ensure the resident can request help, especially in emergencies.
A resident in an LTC facility was found to have five plastic bags tied together as an extension for the overhead light pull-string, creating a non-homelike and potentially hazardous environment. The resident, who was moderately cognitively impaired, expressed frustration with the setup. Facility staff acknowledged the inappropriateness of the situation, which did not align with the facility's policies for maintaining a safe and homelike environment.
A resident with Alzheimer's and diabetes was transferred to a hospital due to urgent medical needs without the facility completing the required Notice of Proposed Transfer/Discharge form. This form, which includes reasons for transfer, destination, and appeal rights, was not provided, violating the facility's policy.
The facility failed to complete the Notification of Bed-Hold and Return forms for two residents transferred to a GACH. One resident, with Alzheimer's and other conditions, had the capacity to make decisions, while the other did not. In both cases, the facility did not discuss the bed-hold policy with the residents or their representatives, and the forms were left blank.
The facility failed to follow up on PASRR evaluations for two residents, one with schizophrenia and another with depression. The first resident required a Level II mental health evaluation, which was not conducted, while the second resident needed a resubmission of a Level I screening after 30 days, which was also not done. The ADON acknowledged the oversight, emphasizing the importance of PASRR evaluations for appropriate care.
A facility failed to set a resident's low air loss (LAL) mattress according to their weight, as required by the manufacturer's guidelines, for a resident with a right heel blood-filled blister. The resident, who had conditions such as atherosclerosis, peripheral vascular disease, and diabetes, was at risk for pressure sores. Despite the care plan and Braden Scale assessment indicating the need for pressure-relieving devices, the mattress was incorrectly set at 240 pounds instead of the resident's actual weight of 184 pounds. This oversight was noted by both the LVN and ADON, highlighting the importance of correct mattress settings for effective pressure sore management.
A resident with an indwelling urinary catheter did not receive appropriate care, as the facility failed to document and report the presence of sediments in the urine and did not securely anchor the catheter tubing. This oversight was contrary to the facility's policies, which required monitoring and physician notification of urine abnormalities. The Director of Nursing confirmed the discrepancies in documentation and catheter care, highlighting a deficiency in the resident's treatment and services.
A resident with osteoarthritis experienced severe pain due to the unavailability of Norco, a prescribed pain medication. The LVN confirmed the medication was not on the cart and stated the resident usually requested acetaminophen instead. Facility policies require timely administration and adequate supply of medications, which were not adhered to in this case.
A resident with atrial fibrillation did not receive the full prescribed dose of warfarin via g-tube, as observed during medication administration. The LVN prepared the medication but left a significant residue in the dosage cup, administering only about half the dose. The incident was documented, and the physician was informed, awaiting new orders.
The facility failed to meet the nutritional needs of residents by not using preparation guides for puree diets and not providing a double portion of protein as ordered for a resident with specific dietary needs. The Dietary Supervisor missed updating the meal ticket, resulting in incorrect meal service.
The facility failed to post accurate nurse staffing information, specifically the actual hours worked by RNs and LVNs/LPNs per shift, over a one-month period. The postings only showed hours worked by licensed nurses per shift without specifying the hours worked by each category, leading to potential misinformation about the nursing care provided. The DON acknowledged the issue, and the ADM was unaware of the inaccuracy, having used the incorrect format for some time.
The facility failed to meet the required room size of 80 square feet per resident in 30 out of 31 rooms. Despite this, residents and staff reported that the room sizes did not hinder care provision or affect comfort. A variance request was submitted, indicating no adverse effects on residents' health or safety.
A resident receiving dialysis treatments three times a week did not receive their morning medications as ordered by the physician due to the facility's standard medication administration time conflicting with the resident's dialysis schedule. The LVN responsible did not administer the medications on dialysis days and failed to seek clarification from the physician, resulting in missed doses. The DON confirmed the lack of documentation and adherence to the facility's medication administration policy.
A resident receiving dialysis treatments did not receive insulin as ordered by the physician on multiple occasions. The resident's MAR indicated insulin was held due to blood sugar levels, but there was no communication with the physician about insulin administration during dialysis days. The facility's policy requires medications to be administered as prescribed, but this was not followed, leading to a significant medication error.
A resident's privacy was compromised when an LVN inspected her G-Tube in the common dining area without enhanced PPE, contrary to the facility's practice of conducting such procedures in private. Another resident reported the incident, believing the resident was being fed publicly, which was confirmed by the facility's administration.
Failure to Notify Physician of Significant Change in Condition for Resident on Anticoagulant Therapy
Penalty
Summary
Licensed nursing staff failed to promptly notify the attending physician or physician assistant of a resident's significant change in condition, despite clear physician orders and care plan instructions to do so. The resident, who had a history of Parkinsonism, dysphagia, chronic kidney disease, hypertension, orthostatic hypotension, and was on long-term anticoagulant therapy (Eliquis), experienced multiple concerning symptoms including altered level of consciousness, shortness of breath, hypotension, and three episodes of coffee-ground emesis over a period of several hours. These symptoms were documented in the resident's records and observed by both licensed nurses and CNAs, but the physician was not notified until after emergency medical services (EMS) were called and the resident was transferred to the hospital. The facility's records and staff interviews revealed that the resident's condition deteriorated over several hours, with repeated episodes of vomiting and declining vital signs. Despite the care plan and physician orders requiring monitoring for adverse reactions to anticoagulant therapy and immediate physician notification for symptoms such as vomiting, bleeding, or changes in mental status, the licensed nurses did not contact the physician or physician assistant during the critical period. Staff interviews indicated a lack of recall regarding the specifics of the resident's symptoms and the timing of events, and documentation was incomplete or inconsistent with observed events. The failure to notify the physician in a timely manner resulted in a delay in diagnosis, care, and emergency interventions for the resident. EMS was eventually called when the resident's condition became critical, and upon arrival, EMS found the resident in respiratory failure with evidence of coffee-ground emesis. The resident was transferred to the hospital, where resuscitation efforts were unsuccessful, and the resident was pronounced dead. The deficiency was identified by surveyors as an Immediate Jeopardy situation due to the facility's noncompliance with requirements for physician notification of significant changes in condition.
Removal Plan
- The DON and Assistant DON (ADON) notified the nursing staff (all licensed nurses) of findings outlined in the IJ and conducted in-services for all nursing staff (21 licensed nurses and 42 certified nursing assistants (CNAs) regarding the Change of Condition policy. The training covered: a. Utilizing the Interact early warning toll-stop and watch technique to report any possible resident's changes in condition. b. Utilizing the SBAR form to record the change of condition to ensure accuracy and completeness that included current vital signs, detailed description of the identified situation, any drainage observed, interventions provided including physician notification. c. The anticoagulant monitoring which includes but not limited to: discolored urine, black tarry stools, nausea/vomiting or diarrhea, bruising/bleeding, abnormal vital signs, shortness of breath, and change in mental status. d. Timely physician notification for the onset of changes in condition, including the identified signs related to anticoagulant adverse reaction monitoring. The DON emphasized the importance of notifying the physician upon identification of the situation to avoid any possible delay.
- The facility pharmacist was contacted and will complete in-service to licensed nurses regarding black box warning. During the in-service, the pharmacist will educate the following areas: a. Following physician's orders/instructions for residents with medications labeled black box warning, such as specific monitoring, laboratory tests, etc., b. Creating and implementing the care plan c. Notifying the physician if any identified signs of adverse reaction
- The DON notified the staff who could not complete the in-services must receive an in-service upon their return before their shift.
- The facility notified the facility Medical Director of the IJ and the IJ Removal Plan. The Medical Director reviewed and approved the IJ removal plan.
- The ADM completed the Quality Assurance and Performance Improvement (QAPI) Plan for identifying and notifying the physician of resident change of condition. The Medical Director will review the QAPI program for change of condition/physician notification every month and assist the facility in adjusting the measures as necessary.
- LVN [1] assigned to Resident 1 received disciplinary action pending investigation. The DON provided one-to-one in-service with LVN 1 regarding physician notification prior to the suspension.
- A total of 28 current residents are receiving anticoagulant therapy. All 28 residents who have anticoagulant orders have monitoring for adverse reactions in the electronic medication administration record.
- The DON will conduct a monthly in-service for nursing staff (licensed nurses and CNAS) regarding change in condition for three months.
- The DON and/or ADON will review the change of condition daily, to ensure timely physician notification of any onset signs or symptoms.
- The DON created a change of condition monitoring log, which includes the physician notification of any changes. The DON notified nursing staff of the monitoring process and will document the findings and corrective action in the monitoring log for three months. If any issues are identified, the DON will extend the monitoring period for an addition of three months.
- The DON/RNS will make daily rounds to ensure that any resident changes in condition is being reported and addressed. The DON/RNS would provide a one-to-one inservice if any issues identified.
- The facility initiated a QAPI for physician notification of changes in condition to address the findings outlined in the IJ template. The facility will review the progress every month for 3 months and adjust the measures as needed to ensure an effective and consistent plan.
Failure to Assess, Monitor, and Care Plan for PAD and Atherosclerosis
Penalty
Summary
The facility failed to properly assess, monitor, and address a resident's diagnoses of Peripheral Arterial Disease (PAD) and atherosclerosis following the resident's recent hospitalization for an acute cerebrovascular accident (CVA), right internal carotid artery stenosis, and PAD. Upon readmission, the facility did not include PAD and atherosclerosis in the resident's cumulative diagnoses list, despite these being documented in the hospital discharge summary. This omission resulted in the lack of a comprehensive and individualized care plan for PAD/PVD and atherosclerosis, and the facility did not follow the hospital physician's recommendations for further vascular assessment and intervention. Licensed staff did not ensure that the resident was referred for an elective bilateral lower extremity arteriogram and endovascular intervention as recommended by the hospital's interventional radiologist. Additionally, the facility failed to consistently monitor and document the resident's bilateral pedal pulses as ordered by the physician, with documentation only for the left pedal pulse and not the right. The order for bilateral pedal pulse monitoring was discontinued without a documented reason. The resident's care plans focused on behavioral management of self-inflicted wounds rather than addressing the underlying vascular issues, and there was no evidence of a root cause analysis or interdisciplinary team review to determine the reason for the resident's scratching behavior. As a result of these deficiencies, the resident experienced a change in condition, including altered level of consciousness and fluctuating oxygen saturation, which led to an emergency transfer to an acute care hospital. At the hospital, the resident was found to have a suspected right lower extremity superficial femoral artery occlusion, cellulitis, gangrenous changes, and septic shock. The resident died two days after hospital admission, with diagnoses including PAD, cellulitis, gangrene, and septic shock. Interviews with facility staff confirmed that the necessary diagnoses and care plans were not established, and that communication and assessment failures contributed to the resident's decline.
Failure to Timely Transmit MDS Assessments
Penalty
Summary
The facility failed to ensure the timely transmission of the Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) system for 11 out of 13 sampled residents. This deficiency was identified through interviews and record reviews, revealing that the MDS assessments were not submitted within the required 14-day period after completion. The delay in submission ranged from 9 to 91 days late, affecting residents with various diagnoses including dementia, hyperlipidemia, heart failure, bipolar disorder, diabetes mellitus, Parkinson's disease, schizophrenia, and chronic obstructive pulmonary disease. The MDS Nurse (MDSN) acknowledged the failure to transmit the MDS assessments timely, citing being overwhelmed with other responsibilities despite having additional support from a part-time MDSN. The MDSN admitted to not being able to fulfill her duties effectively, which resulted in the late submissions. The Administrator (ADM) and Director of Nurses (DON) were aware of the issue, emphasizing the importance of timely MDS submissions to ensure accurate resident assessments and the development of appropriate care plans. The facility's policy and procedure, as well as the CMS Long-Term Care Facility MDS 3.0 RAI User's Manual, require MDS assessments to be submitted within 14 days of completion. However, the facility did not adhere to these guidelines, leading to potential confusion regarding resident care and impacting the facility's quality of care monitoring system. The deficiency was documented for residents with significant medical conditions, highlighting the critical need for timely and accurate data submission to support effective resident care management.
Improper Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to adhere to proper sanitation and food handling practices as outlined in their policy and procedure. During a kitchen observation, a scoop was found inside a thickener container with its handle touching the contents. This was observed in the presence of the Dietary Supervisor (DS), who acknowledged that the scoop should not have been left inside the container. The handle's contact with the contents could introduce bacteria or other contaminants, leading to cross-contamination. The facility's policy on the storage of canned and dry goods specifies that scoops should not be left in containers and must be cleaned after each use.
Failure to Transmit MDS Timely
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to develop and evaluate a plan to ensure the timely transmission of the Minimum Data Set (MDS) to the Centers for Medicare and Medicaid Services (CMS) system. This deficiency was identified during a survey conducted from December 18 to December 21, 2023, and affected 11 out of 13 sampled residents. The late transmission of MDS assessments was a recurring issue from the previous annual recertification survey, indicating a persistent problem in the facility's processes. The report details several instances of late MDS submissions for residents with various medical conditions, including dementia, hyperlipidemia, heart failure, bipolar disorder, diabetes mellitus, Parkinson's disease, and others. For example, Resident 2's MDS was completed on November 26, 2024, but was not transmitted until December 19, 2024, nine days past the due date. Similarly, Resident 24's MDS was submitted 28 days late, and Resident 25's MDS was 68 days late. These delays in submission were consistent across multiple residents, with some submissions being as late as 91 days. Interviews with the MDS Nurse (MDSN) and the Director of Nurses (DON) revealed that the MDSN was aware of the issue but was unable to submit the MDS assessments on time due to being occupied with other responsibilities. Despite hiring a part-time MDS Nurse to assist, the problem persisted. The Administrator (ADM) acknowledged the deficiency and noted that while they had verbally communicated the issue and attempted to address it by hiring additional staff, there was no documented plan in the facility's QAPI to resolve the issue. The facility's policy on QAPI emphasized the importance of tracking and measuring performance, identifying deficiencies, and implementing corrective actions, but these steps were not effectively executed in this case.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as Resident 14, by not ensuring that the call light was within reach. Resident 14, who was originally admitted on 7/31/2024 and readmitted later, had diagnoses including generalized anxiety disorder, difficulty walking, and generalized muscle weakness. The Minimum Data Set (MDS) assessment indicated that Resident 14 required varying levels of assistance with daily activities, including supervision with eating and full assistance with bathing and toileting. The resident's care plan specifically included the requirement to keep the call light within reach to attend to needs promptly. During an observation, it was noted that the call light was placed on top of the bedside table, out of reach for Resident 14, who was in bed and unable to reach it. Licensed Vocational Nurse (LVN) 1 confirmed that the resident could not access the call light in its current position and acknowledged that it should always be accessible as per the facility's policy. The Assistant Director of Nursing (ADON) also stated that the call light should be within reach to ensure the resident can request assistance, especially during emergencies. The facility's policies on answering call lights and accommodating resident needs emphasize the importance of accessibility and timely response to resident requests.
Inappropriate Use of Plastic Bags for Light Pull-String
Penalty
Summary
The facility failed to provide a safe and homelike environment for a resident, identified as Resident 50, who had five plastic bags tied together and used as an extension to pull the string to turn on and off the overhead light above the bed. This setup was observed during a survey, and it was noted that the use of plastic bags as an extension could potentially cause an accident and did not promote a homelike environment. Resident 50, who was moderately cognitively impaired and required assistance with daily activities, expressed frustration and dissatisfaction with the makeshift pull-string, stating it looked bad and was bothersome. Interviews with facility staff, including a Licensed Vocational Nurse, Maintenance Supervisor, and Assistant Director of Nurses, confirmed that the use of plastic bags as a pull-string extension was inappropriate, potentially hazardous, and not in line with the facility's policies for maintaining a homelike environment. The facility's policies emphasized the importance of providing a safe, clean, and comfortable environment, and ensuring all equipment is kept in operable condition. The deficiency was identified as a failure to adhere to these policies, resulting in a non-homelike and potentially unsafe environment for Resident 50.
Failure to Provide Proper Transfer/Discharge Notification
Penalty
Summary
The facility failed to ensure proper notification procedures were followed for a resident's transfer or discharge. Specifically, the Notice of Proposed Transfer/Discharge form for a resident was not completed in accordance with the facility's policy and procedure. This form is crucial as it includes the reason for the transfer or discharge, the destination, contact information for the State Long Term Care Ombudsman, and details on how to appeal the transfer or discharge. The deficiency was identified during a review of the resident's records and an interview with the Director of Nursing, who confirmed that the necessary form was not completed. The resident involved had been admitted to the facility with diagnoses including Alzheimer's disease and diabetes mellitus. The resident's cognitive skills were severely impaired, requiring supervision and extensive assistance for daily activities. A Change in Condition Evaluation indicated the resident developed a cough, lung congestion, and diarrhea, leading to a transfer to a General Acute Care Hospital. Despite the urgent medical needs necessitating the transfer, the facility's policy required that the resident or their representative be notified in writing as soon as practicable, which was not done in this case.
Failure to Complete Bed-Hold Notification Forms
Penalty
Summary
The facility failed to complete the Notification of Bed-Hold and Return form for two residents who were transferred to a General Acute Care Hospital (GACH) as ordered by their physicians. Resident 38, who was admitted with Alzheimer's disease, end-stage renal disease, and heart failure, had the mental capacity to make medical decisions and was cognitively intact. Despite this, there was no indication in Resident 38's clinical record that the facility staff discussed the Notification of Bed-Hold and Return with the resident or their responsible party when the resident was transferred to the GACH. The seven-day bed hold notification form was not completed and was left blank at the time of transfer. Similarly, Resident 58, who was admitted with Alzheimer's disease and diabetes mellitus, did not have the mental capacity to make medical decisions and required supervision for daily activities. The facility also failed to discuss the Notification of Bed-Hold and Return with Resident 58 or their responsible party when the resident was transferred to the GACH. The seven-day bed hold notification form for Resident 58 was also left blank. The Director of Nursing acknowledged that the bed hold notification forms should have been completed and signed by either the resident or their responsible party, as per the facility's policy and procedure.
Failure to Follow Up on PASRR Evaluations for Two Residents
Penalty
Summary
The facility failed to follow up on the Preadmission Screening and Resident Review (PASRR) evaluations for two residents, leading to potential deficiencies in their care. Resident 49, who was admitted with diagnoses including schizophrenia, anxiety disorder, and major depressive disorder, had a positive PASRR Level I screening on April 29, 2022, indicating the need for a Level II mental health evaluation. Despite this requirement, the facility did not conduct the necessary follow-up, and the resident continued to exhibit episodes of yelling and profanity, which were managed by staff through monitoring and redirection. Resident 69, admitted with a diagnosis of depression, had a negative PASRR Level I screening on June 3, 2024, with instructions to resubmit a PASRR Level I screening if the resident remained in the facility for more than 30 days. The resident stayed in the facility for over six months without the required resubmission of the screening. The resident was observed to be dependent on staff for daily activities and exhibited signs of depression, such as a sad demeanor. The Assistant Director of Nurses (ADON) acknowledged the oversight in both cases, stating the importance of PASRR evaluations to ensure residents receive appropriate care and services. The facility's policy on PASRR, dated July 1, 2023, outlines the procedures for conducting and following up on PASRR screenings, which were not adhered to in these instances.
Incorrect LAL Mattress Setting for Resident with Pressure Ulcer Risk
Penalty
Summary
The facility failed to ensure that a resident with a right heel blood-filled blister had their low air loss (LAL) mattress set according to their weight, as per the manufacturer's guidelines. The resident, who was admitted with conditions including atherosclerosis, peripheral vascular disease, and diabetes mellitus, was at risk of developing pressure sores. The resident's care plan included the use of pressure-relieving devices, and the Braden Scale assessment indicated a risk for pressure sores. However, during an observation, it was noted that the LAL mattress was set at 240 pounds, while the resident's actual weight was 184 pounds. This incorrect setting was acknowledged by the Licensed Vocational Nurse (LVN) and the Assistant Director of Nurses (ADON), who both emphasized the importance of setting the mattress correctly for effective pressure sore management. The facility's policy and procedure documents, as well as the manufacturer's guidelines, indicated that the LAL mattress should be adjusted according to the resident's weight to prevent and minimize pressure on the skin. Despite this, the mattress was not set correctly, which had the potential to delay the healing of the resident's right heel blister. Observations and interviews with the Treatment Nurse (TN) further confirmed the importance of the correct mattress setting for wound healing. The facility's failure to adhere to these guidelines and policies resulted in a deficiency that could negatively impact the resident's quality of life.
Deficiency in Catheter Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with an indwelling urinary catheter, leading to a deficiency in care. The resident, who was admitted with diagnoses including muscle weakness and chronic kidney disease, had an indwelling catheter due to benign prostate hyperplasia. The facility's care plan for the resident included monitoring urine for sediment, cloudiness, odor, blood, and amount of urine output to reduce the risk of infection. However, observations revealed that the resident's catheter tubing contained cloudy urine and sediments, which were not documented in the Treatment Administration Record (TAR) as required. Additionally, the catheter tubing was not securely anchored, increasing the risk of dislodgement and potential trauma or infection. The facility's policies required staff to monitor and document the characteristics of the resident's urine and to notify the physician of any abnormalities. Despite these requirements, the Director of Nursing acknowledged that the TAR did not accurately reflect the resident's urine characteristics, and the nursing staff failed to report the presence of sediments to the physician. The facility's policy also mandated that the catheter tubing be securely anchored to prevent dislodgement, which was not adhered to in this case. These lapses in care had the potential to result in significant harm to the resident, including urethral and bladder trauma, pain, and untreated infection.
Failure to Maintain Adequate Supply of Pain Medication
Penalty
Summary
The facility failed to ensure an adequate supply of Norco, a pain medication, was available for a resident with an active physician order. The resident, who was diagnosed with osteoarthritis of the knee, was observed experiencing pain rated at 7/10 in both knees and the left shoulder. Despite the physician's order for Norco to be administered every four hours as needed for severe pain, the medication was unavailable during the observation. The Licensed Vocational Nurse (LVN) confirmed that the Norco was not on the medication cart and stated that the resident typically requested acetaminophen instead. The LVN acknowledged that the facility is required to have all medications available for residents with active physician orders. The facility's policy on administering medications emphasizes that medications should be administered safely, timely, and as prescribed. Additionally, the policy on ordering and receiving medications from the dispensing pharmacy requires medications to be reordered five days in advance to ensure an adequate supply. The LVN indicated that the physician should be contacted to clarify the orders if the resident uses Norco infrequently.
Incomplete Administration of Warfarin via G-Tube
Penalty
Summary
The facility failed to ensure the complete administration of a prescribed dose of warfarin to a resident via a gastrostomy tube, as observed during a medication administration. The resident, who was admitted with a diagnosis of paroxysmal atrial fibrillation, was prescribed warfarin 2.5 mg daily to prevent blood clots. During the medication pass, the Licensed Vocational Nurse (LVN) prepared the medication by crushing the tablet and mixing it with water. However, a significant amount of the medication remained in the dosage cup after administration, indicating that only approximately half of the dose was given. The LVN acknowledged the incomplete administration and noted the incident in the resident's Medication Administration Record, indicating that the physician was informed and new orders were awaited. The facility's policy on administering medications, which requires medications to be administered as prescribed, was not followed in this instance. This deficiency in medication administration could potentially increase the resident's risk of medical complications, as noted by the LVN during the interview.
Failure to Follow Dietary Orders and Preparation Guidelines
Penalty
Summary
The facility failed to ensure that menus met the nutritional needs of residents, particularly those on puree diets and those with specific dietary orders. During observations, it was noted that dietary staff did not have access to or use preparation guides and recipes while preparing puree diets and thickened liquids for 18 residents. The Dietary Supervisor confirmed that the absence of preparation guides could lead to incorrect proportions, affecting the texture and safety of the meals for residents with swallowing difficulties. The facility's policy required standardized recipes to be accessible to dietary staff, which was not adhered to during the preparation process. Additionally, the facility did not comply with a physician's order for a resident requiring a double portion of protein at all meals. The resident, who had end-stage renal disease and diabetes mellitus, did not receive the prescribed double portion of protein during meal observations. The meal ticket did not reflect the dietary order, and the Treatment Nurse confirmed the discrepancy. The Dietary Supervisor acknowledged missing the order update, which resulted in the resident not receiving the correct meal as prescribed. The facility's policy on diet orders required nursing staff to transcribe physician orders onto a Diet Order Communication form and send it to the dietary department before meal services. However, a review of the binder containing dietary orders revealed no update for the resident's double portion of protein requirement. This oversight led to the resident not receiving the necessary nutrition as per their dietary needs.
Inaccurate Nurse Staffing Information Posted
Penalty
Summary
The facility failed to post accurate nurse staffing information, specifically the actual hours worked by Registered Nurses (RNs) and Licensed Vocational Nurses (LVNs)/Licensed Practical Nurses (LPNs) per shift, over a one-month period from November 17, 2024, to December 17, 2024. The facility's policy, titled 'Posting Direct Care Daily Staffing Numbers,' requires that the number of nursing personnel responsible for providing direct care to residents be posted daily, including specific hours worked by RNs and LVNs/LPNs. However, the facility's postings only showed hours worked by licensed nurses per shift without specifying the hours worked by each category of nurse, which could lead to misinformation about the nursing care provided. During an interview and record review on December 17, 2024, the Director of Nurses (DON) acknowledged that the daily nursing postings did not indicate specific hours worked by RNs and LVNs/LPNs as required by the facility's policy. The Administrator (ADM) was unaware of the inaccuracy in the facility's daily nursing postings and had been using the incorrect format for some time. The facility's policy, revised in August 2022, mandates that nurse staffing data, including the type and category of nursing staff and the actual time worked during each shift, be posted in a prominent location within two hours of the beginning of each shift. The failure to adhere to this policy resulted in the posting of inaccurate nurse staffing information.
Room Size Deficiency in Resident Bedrooms
Penalty
Summary
The facility failed to ensure that resident bedrooms met the required minimum size of 80 square feet per resident in multiple occupancy rooms. During a survey, it was found that 30 out of 31 rooms did not meet this requirement, with room sizes ranging from 138.92 to 314.27 square feet, accommodating two to four residents each. This deficiency was identified through a Client Accommodations Analysis and confirmed by observations and interviews with residents and staff. Despite the deficiency, residents and staff reported that the room sizes did not hinder the provision of care or affect residents' comfort and privacy. Interviews with residents and staff indicated that the current room sizes allowed for adequate movement and care provision. Residents expressed satisfaction with their room sizes, stating that they did not impact their comfort or care. Staff, including CNAs and LVNs, reported that they could safely maneuver equipment and provide necessary care within the existing room dimensions. The facility also submitted a variance request, indicating that the room sizes did not adversely affect residents' health, safety, or well-being.
Failure to Administer Medications as Ordered for Dialysis Resident
Penalty
Summary
The facility failed to administer morning medications as ordered by the physician for a resident who receives dialysis treatments three times a week. The resident, who was admitted with diagnoses including end-stage renal disease, dependence on renal dialysis, hyperglycemia, and hypertension, was scheduled to leave the facility for dialysis at 7:45 AM. However, the facility's standard medication administration time was 9 AM, and the resident was not present to receive the medications at that time. Licensed Vocational Nurse (LVN) 1, responsible for administering medications, stated that the resident usually left for dialysis between 6:30 AM and 7:00 AM and returned around 11:30 AM to noon. LVN 1 did not administer the 9 AM medications on dialysis days, as the resident was not present, and did not contact the attending physician to clarify whether the medications should be held or administered at a different time. This resulted in the resident not receiving their prescribed medications on multiple occasions throughout July 2024. The Director of Nursing (DON) confirmed that there was no documented evidence of the resident receiving the 9 AM medications on the specified dates and that the staff should have sought clarification from the physician. The facility's policy on medication administration emphasized the importance of administering medications as prescribed and considering resident needs and preferences. However, the staff failed to adhere to this policy, leading to the deficiency in medication administration for the resident.
Failure to Administer Insulin as Ordered for Dialysis Patient
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering insulin as ordered by the physician. The resident, who was receiving dialysis treatments three times a week, had a physician's order for Insulin Aspart to be administered subcutaneously with meals, unless the blood sugar was less than 70. However, the Medication Administration Record (MAR) for July 2024 showed that the insulin was not administered on several occasions, with codes indicating drug refusal or other reasons noted in progress notes. The resident, who had diagnoses including end-stage renal disease, hyperglycemia, and hypertension, was noted to have moderately impaired cognition. Despite this, the resident's insulin was held on multiple occasions due to blood sugar levels being above 70 but below the threshold for holding insulin. The Licensed Vocational Nurse (LVN) and Director of Nursing (DON) confirmed that there was no communication with the physician regarding whether insulin should be administered or held on dialysis days, and there was no documented evidence of insulin administration on the specified dates. The facility's policy on administering medication requires that medications be administered as prescribed and in a timely manner. However, the lack of communication with the physician and the absence of documented orders to hold insulin during dialysis treatments contributed to the medication error. The facility's policy also emphasizes the importance of ensuring that medications are administered according to prescriber orders and that any deviations are properly documented and communicated, which was not adhered to in this case.
Failure to Maintain Resident Privacy During G-Tube Inspection
Penalty
Summary
The facility failed to maintain the bodily privacy of a resident, identified as Resident 4, during an inspection of her G-Tube in the common dining area. Resident 4, who was admitted with diagnoses including dysphagia and gastro-esophageal reflux disease, requires maximum assistance for all self-care tasks and has a care plan that emphasizes maintaining privacy during enteral feeding. Despite this, an LVN checked Resident 4's G-Tube in the dining area without enhanced PPE, which was against the facility's practice of providing such care in the privacy of the resident's room. The incident was reported by another resident, Resident 1, who observed the LVN handling a container with liquid and visualizing the G-Tube, leading her to believe that Resident 4 was being fed inappropriately in a public setting. The LVN and the facility's administration, including the DON, confirmed that the G-Tube was only being checked to ensure the valve was closed, but acknowledged that the action took place in the dining area, which compromised Resident 4's privacy and dignity.
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Nursing homes near Glendale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Royal Palms Post Acute | 0 mi | — | 34 | 0 |
| Chestnut Ridge Post Acute Llc | 0.8 mi | — | 33 | 1 |
| Golden Haven Care Center | 1.1 mi | — | 15 | 0 |
| Glenhaven Healthcare | 1.1 mi | — | 14 | 0 |
| Glendale Healthcare Center | 1.2 mi | — | 10 | 0 |
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