Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 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.
Failure to Validate Water Management Program With Ongoing Legionella Testing: The facility did not perform ongoing water sample testing to validate its water management program or confirm that control measures were effective against waterborne pathogens such as Legionella. The IP stated annual testing was not done, only initial testing had been completed after a prior Legionella outbreak, and no testing had occurred since the UV water treatment system was added. The MS confirmed the facility had not done any water testing or validation since 2018, despite the facility policy calling for monitoring control limits and effectiveness of control measures.
Food service staff failed to maintain sanitary conditions and proper portion control. A can opener was observed chipped and peeling, a garlic powder container lid was left open, and a DA served pureed rice soup to 6 residents without measuring the portions. The DS and other staff stated food containers should be kept closed, equipment should be in good condition, and servings should be measured to maintain portion control.
A resident with dementia and impaired communication had a call light hanging out of reach, another resident with dementia and hearing deficit had a call light hidden behind the bed rail and out of reach, and a third resident with dementia had a call light that did not work when pressed. Staff and the DON stated call lights should be within reach and functioning so residents can use them to get help.
A resident with an indwelling FC was observed with the drainage bag visible and not placed in a dignity bag, and staff confirmed it should have been covered for privacy and dignity. Another resident was observed after breakfast still wearing a soiled bib, and CNA and LVN staff stated the bib should have been removed and the resident cleaned promptly to maintain dignity and respect.
PRN Ativan Extended Without Required Rationale A resident with anxiety disorder, schizophrenia, and major depressive disorder had a PRN Ativan order continued for 90 days without documented rationale to extend use beyond the 14-day limit in the facility policy. The LVN, MDS nurse, and DON all confirmed there was no psychiatrist documentation supporting the extended PRN psychotropic order.
Failure to care plan a resident's hearing aid use. A resident with Meniere's disease and severe cognitive impairment was documented as hard of hearing and had two hearing aids, but the EMR care plan only addressed communication deficit related to hearing loss and did not include the resident's hearing aids. The IP and MDSN stated the resident's hearing aid use should have been care planned so staff would know the resident needed the assistive devices for communication.
Improper Broda Chair Size and Bedside Rail Positioning: A resident with dementia and a stage 4 sacral pressure ulcer was observed seated in a Broda chair that was too short, leaving both lower legs hanging without support. Staff, including the DOR and DON, confirmed the chair did not fit the resident and should have been replaced. Another resident with dementia and gait/mobility issues had an order for bilateral half siderails, but one rail was observed upright while the resident was in bed; staff stated the rails should have been positioned horizontally while in bed.
A resident with dementia, unsteady gait, difficulty walking, wandering behavior, and multiple prior falls was observed ambulating in the hallway without a FWW and without staff present. The care plan called for hourly monitoring for whereabouts and reminders to use assistive devices, but interviews and record review showed the resident continued to walk without the walker, the fall care plan was not revised after earlier falls, and there was no documentation that hourly monitoring was completed.
A resident with a GT, severe cognitive impairment, hemiplegia, and heart failure was observed receiving Fiber source at 60 ml/hr even though the current physician order was 50 ml/hr. An LVN confirmed staff continued the prior pump settings after the order changed, and the facility policy required checking the enteral nutrition label against the order before administration.
A resident with chronic back pain, osteoarthritis, pyoderma gangrenosum, and hospice care did not receive scheduled morphine ER as ordered, missing two doses when the medication was not delivered. The resident also reported increased pain, asked an LPN for pain medicine, and was later heard screaming in distress. Staff stated the missed doses were not communicated to hospice, and the resident’s pain was not managed by the current regimen.
Incomplete Physician Discharge Summary: A resident admitted with a left femur fracture, orthopedic aftercare needs, and atrial fibrillation had severely impaired cognitive decision-making and required extensive assistance with ADLs. The PDS was left incomplete because the resident’s condition and prognosis on discharge were blank, and staff interviews confirmed the MR was responsible for obtaining the physician’s completion and signature, with the DP and DON identifying that the discharge document should have been verified as complete.
A resident room was observed with 5 beds occupied by 5 residents, exceeding the limit of no more than 4 residents per room. The room waiver showed the room was 511 sq. ft. with 5 beds, and the ADM acknowledged the room did not meet the requirement for only 4 residents in one room. Staff stated the room had enough space for care and resident movement, and the facility later requested continued waiver consideration.
Insufficient Square Footage in Multiple Resident Rooms: A facility failed to ensure 14 multiple-occupancy resident rooms met the required 80 sq. ft. per resident. Surveyors observed the rooms and found that residents could move around freely and staff had enough space to provide care, while the facility’s room waiver showed the 2-bed rooms were slightly below the 160 sq. ft. minimum. An LVN, CNAs, and the ADM stated the rooms had adequate space, and residents did not report concerns about room size.
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.
Failure to Validate Water Management Program With Ongoing Legionella Testing
Penalty
Summary
The facility did not implement ongoing water sample testing to validate its water management program control measures and confirm that the facility’s water was free of waterborne pathogens such as Legionella. During an interview, the Infection Preventionist stated the facility did not do any annual water testing to validate its controls because she believed it was not required by CMS. She also stated the only initial testing had been done a long time ago when the facility had a Legionella outbreak, and that after the ultraviolet (UV) light water treatment system was added, no further water testing had been performed. During another interview, the Infection Preventionist stated validation would only be done if a control measure was not met or not effective, and that the facility’s controls were considered to be working because there had not been any residents with Legionella. The Maintenance Supervisor stated the facility had a case of Legionella in 2018, that water testing was done after the UV light water treatment system was incorporated, and that no water testing had been done since 2018. He also stated the facility did not do any validation of its controls. Review of the facility’s Legionella Water Management Program policy, revised September 2022, showed the facility was committed to the prevention, detection, and control of water-borne contaminants, including Legionella, and that the program included specific control measures and a system to monitor control limits and the effectiveness of control measures. Review of the CDC toolkit and CMS guidance, along with ASHRAE guidance, showed that facilities should establish procedures to confirm, initially and on an ongoing basis, that the water management program is effective and that environmental testing for Legionella may be used to validate control measures. The facility had only performed initial testing in 2018 and did not perform any water testing afterward.
Food Service Sanitation and Portion Control Deficiencies
Penalty
Summary
The facility failed to ensure proper food handling practices and to maintain the food service area in a clean and sanitary condition. During observation in the kitchen, the can opener was noted to be chipped and peeling, and the plastic lid on a garlic powder container stored on a stainless-steel wall shelf was observed to be open. The Dietary Supervisor confirmed the can opener was chipped and peeling and stated the garlic powder container lid was not closed. Facility staff also stated that food containers were supposed to be properly closed at all times and that equipment was supposed to be in good condition. The facility also failed to ensure portion control during tray line service. During lunch preparation, a Dietary Aide poured pureed rice soup into 6 bowls for 6 residents without measuring the portions. The Dietary Aide later stated she poured the soup from a stainless-steel container into the bowls without measuring and said she should have used a 6-oz ladle for proper portion control. The Dietary Supervisor stated food was supposed to be measured at all times to ensure residents received the right amount of nutrition and to maintain portion control. Facility policies reviewed included requirements for safe food handling, keeping utensils and equipment in good repair, and using proper serving measurements.
Call Lights Not Accessible or Functional
Penalty
Summary
The facility failed to ensure that a working call system was available and within reach for residents in their rooms, bathrooms, and bathing areas, as required by its policy titled Answering the Call Light. During observation, Resident 7, who had diagnoses including hypertension, dementia, and muscle weakness and was assessed as severely cognitively impaired and dependent for several activities of daily living, had a call light hanging on the right side of the bed facing the floor and out of reach. Resident 7’s care plan also identified a communication problem related to a language barrier, noted the resident was nonverbal and had impaired vision, and directed that the call light be kept within reach. Resident 19, who had diagnoses including hypotension and dementia and was also assessed as severely cognitively impaired and dependent for multiple activities of daily living, had a care plan identifying a communication problem related to hearing deficit and a fall risk related to limited mobility, with interventions to keep the call light within reach. During observation, Resident 19’s call light was hanging off the right side of the bed behind the upper right quarter side rail and was not within reach. The resident stated she could not find or reach the call light and said, "They always hide it from me." Staff observed the call light out of reach and confirmed it was not accessible. Resident 18, who had diagnoses including dementia and hypertensive chronic kidney disease and was assessed as severely cognitively impaired and dependent for several transfers and dressing tasks, had a care plan identifying fall risk and directing that the call light be within reach. During observation, Resident 18’s call light did not work when the button was pressed and did not light up to alert staff. A CNA confirmed the call light was not working. Interviews with nursing staff and the DON stated that call lights should be within residents’ reach and functioning at all times so residents can call for help.
Failure to Maintain Resident Dignity During Catheter Care and Mealtime Hygiene
Penalty
Summary
The facility failed to promote respect and dignity for two residents. Resident 7 had diagnoses including hypertension, dementia, and muscle weakness, and the MDS indicated severely impaired cognitive skills for daily decision making, dependence on personal hygiene and bed mobility, and the presence of an indwelling catheter. The physician’s order specified a Foley catheter to bedside drainage, but during observation on 2/4/2026, Resident 7 was sitting in a Broda chair with the catheter drainage bag visible and not covered by a dignity bag. During the same observation, LVN 2 confirmed that Resident 7’s Foley catheter drainage bag was not covered. Later interviews with LVN 2 and LVN 3 stated that the drainage bag should have been placed in a dignity bag to provide privacy and dignity and to prevent emotional distress or embarrassment if the urine bag was seen by others. Resident 12 had diagnoses including hypertension, dementia, and major depressive disorder, and the MDS indicated severely impaired cognitive skills, partial/moderate assistance with eating, and dependence on personal hygiene and bed mobility. The care plan called for staff assistance with ADLs, including personal hygiene and eating. During observation on 2/6/2026 after breakfast, Resident 12 was lying in bed wearing a bib soiled with food from breakfast. CNA 6 stated the bib should have been removed and the resident cleaned right after eating, and LVN 3 stated the soiled bib was not acceptable and that residents need to be cleaned after each meal to maintain dignity and respect.
PRN Ativan Extended Beyond Allowed Duration Without Documented Rationale
Penalty
Summary
The facility failed to ensure one sampled resident was free from an unnecessary psychotropic medication by allowing an Ativan PRN order to remain in place for 90 days without a documented rationale for extending use beyond 14 days, as required by the facility policy. Resident 39 was admitted and later readmitted to the facility with diagnoses including anxiety disorder, schizophrenia, and major depressive disorder. The resident’s MDS indicated intact cognitive skills for daily decision making, symptoms of feeling down, depressed, and hopeless, and dependence or substantial assistance with several activities of daily living. The resident was also receiving antipsychotic medications. The resident’s order summary showed Ativan 1 mg by mouth every four hours as needed for anxiety, ordered on 1/30/2026 with an end date of 4/30/2026. During record review and interviews, LVN 3 confirmed the order and stated there was no documented reason in the medical record to support keeping the PRN Ativan order for 90 days instead of limiting it to 14 days. The MDS nurse stated PRN Ativan should be limited to 14 days to minimize psychotropic use and that psychiatrist reevaluation and rationale documentation were needed for continuation beyond that period. The DON also stated there was no psychiatrist documentation prior to the 90-day PRN Ativan order. The facility policy stated PRN psychotropic medication orders are limited to 14 days unless the prescriber documents the rationale and duration for extending use.
Failure to Care Plan Hearing Aid Use
Penalty
Summary
The facility failed to develop a person-centered care plan to address the use of hearing aids for Resident 19. The resident was admitted and later readmitted with a diagnosis of Meniere's disease, and the MDS dated 1/7/2026 indicated the resident was severely impaired in cognitive skills for daily decision making and use of hearing aids. The MDS also showed the resident was dependent with several activities of daily living, including transfers, dressing, and footwear, and required substantial to maximal assistance with upper body dressing, personal hygiene, and eating. During interview, Resident 19 stated she was hard of hearing and needed hearing aids. Review of the clothing and possessions inventory showed the resident had two hearing aids, and the EMR showed a care plan for communication deficit related to hearing deficit, but it did not address the resident's need and use of hearing aids. The IP stated no care plan was created to address the resident's use of hearing aids, and the MDSN stated the resident's hard of hearing status and use of hearing aids should have been care planned so staff would know she needed hearing aids to aid communication.
Improper Broda Chair Size and Bedside Rail Positioning
Penalty
Summary
Resident 7 was admitted with diagnoses including hypertension, dementia, and a stage 4 sacral pressure ulcer. The resident’s PT evaluation and plan of treatment indicated sitting up in a broda chair to encourage socialization and relieve pressure, and the resident’s MDS showed severely impaired cognitive skills, dependence for several activities, and high risk for pressure ulcer development. The care plan also included an intervention to ensure the resident’s comfort related to risk for pressure sore or potential for pressure ulcer development. On observation, Resident 7 was seated in a broda chair that was too short for the resident, with both lower legs hanging and no support below the knees. An LVN confirmed the chair was short and the resident’s feet were hanging. The DOR reviewed the PT evaluation and stated the broda chair was not acceptable because it was too short, and that the resident’s lower legs were not supposed to be hanging. The DON stated that once staff found out the broda chair was too short, it should have been changed or replaced, and stated there was a lack of judgment and supervision because the chair was not changed to a size that fit the resident. Resident 34 had diagnoses including dementia, abnormalities of gait and mobility, and lack of coordination. The resident had an order for half bilateral siderails for bed mobility and transfers, and the MDS showed severely impaired cognitive skills and varying levels of assistance needed for daily care and bed mobility. The care plan stated the resident may have half assistive side rails for bed mobility and may put the side rail up during ADLs. During observation, one half bedside rail on the right side of the bed was seen in the vertical position while the resident was in bed. RN 1 stated the resident had an order for both bedside rails for safety and per family request, while COTA 2 and LVN 3 stated the rails should be positioned horizontally while the resident was in bed and that both rails should be properly positioned.
Inadequate supervision and failure to use walker for a resident with wandering and falls
Penalty
Summary
The facility failed to provide adequate supervision and assistive device use for Resident 41, who had diagnoses including dementia, osteoarthritis, unsteadiness on feet, and difficulty walking. The resident’s MDS indicated severely impaired cognitive skills for daily decision making and need for assistance with multiple activities of daily living, including walking. The care plan identified the resident as at risk for wandering/elopement and for falls related to cognitive impairment, history of falls, unsteady gait, and dementia, with interventions including hourly monitoring for whereabouts related to wandering and reminders to use ambulation and transfer assist devices. Resident 41 had multiple documented falls in the facility, including falls in the hallway, while ambulating, in the nursing station, and while found in another resident’s room sitting on the floor. The care plan was revised after the 1/19/2026 fall, but the record review and interviews showed it was not revised after earlier falls on 11/9/2025 and 11/23/2025. During observations on 2/4/2026 and 2/6/2026, Resident 41 was seen walking in the hallway without a front wheeled walker and without facility staff present to monitor the resident. Interviews with the PTA, DOR, MDS nurse, and DON confirmed that Resident 41 tended to walk until tired, wandered in the facility, and had multiple falls, yet the front wheeled walker was not being used during the observed ambulation. The DOR stated the walker should have been taught and encouraged whenever the resident ambulated, and the DON stated there was no documentation that hourly monitoring for wandering was completed. The DON also stated the walker had been recently added to the care plan because the resident sometimes forgot to use it, but it was not implemented during the observed events.
GT Feeding Pump Settings Not Updated to Match Physician Order
Penalty
Summary
The facility failed to ensure a resident with a gastrostomy tube received tube feeding at the rate ordered by the physician. Resident 47 was admitted and readmitted with diagnoses including hemiplegia, gastrostomy status, and heart failure. The resident’s MDS dated 8/31/2025 indicated severe cognitive impairment for daily decision making and dependence for oral hygiene, toileting hygiene, showering, upper and lower body dressing, footwear, and personal hygiene. During observation on 2/4/2026, Resident 47 was seen in bed with Fiber source tube feeding running at 60 ml per hour. On 2/5/2026, review of the active physician’s orders showed the current GT feeding order was Fiber source 1000 ml/1200 kcal at 50 ml per hour for 20 hours or until dose met, off at 10 AM and start at 2 PM, ordered on 2/1/2026. LVN 3 confirmed the observed 60 ml per hour rate was the previous order and stated staff kept the pump settings from the prior order instead of changing them when the order changed. The facility’s policy on enteral feeding safety precautions stated to check the enteral nutrition label against the order before administration.
Failure to Provide Ordered Pain Medication
Penalty
Summary
Safe, appropriate pain management was not provided for Resident 39, who had diagnoses including dorsalgia, osteoarthritis, and pyoderma gangrenosum and was receiving hospice services. The resident’s MDS indicated intact cognitive skills and that the resident received scheduled and as-needed pain medication, including opioids. The physician’s orders included morphine sulfate oral solution 20 mg SL every 4 hours as needed for severe pain or shortness of breath, and morphine sulfate ER 30 mg by mouth every 12 hours for chronic lower back pain. On 2/4/2026, a change-of-condition note documented increased pain with a pain score of 7/10, generalized body pain, and that the resident’s pain was not managed by the current pain regimen. During observation that morning, the resident asked LVN 3 for pain medication, and later was heard screaming for pain medicine and appeared distressed. LVN 3 stated the resident received morphine sulfate 20 mg SL at 6:30 AM and then received another dose around 10:30 AM because the order allowed administration every 4 hours. Record review and staff interviews showed the scheduled morphine sulfate ER 30 mg doses were not given on 2/3/2026 at 9 PM and 2/4/2026 at 9 AM. LVN 3 stated the medication was pending pharmacy delivery and later noted it was not delivered, resulting in two missed doses. The hospice nurse stated he was not made aware that the medication had not been delivered, and the MDS nurse and DON both stated the licensed nurse should have contacted hospice regarding the unavailable medication. The facility policy stated the medication regimen is to be implemented as ordered and that results are to be documented and communicated directly to the provider when appropriate.
Incomplete Physician Discharge Summary
Penalty
Summary
The facility failed to complete the Physician Discharge Summary (PDS) for Resident 61. Resident 61 was admitted with diagnoses including a displaced intertrochanteric fracture of the left femur, encounter for other orthopedic aftercare, and unspecified atrial fibrillation. The MDS dated 11/30/2025 indicated the resident had severely impaired cognitive decision-making skills and was dependent for toileting hygiene, showering, bathing, lower body dressing, footwear, change of position, and transfers, with partial or moderate assistance needed for oral hygiene, personal hygiene, and upper body dressing. A review of the PDS dated 12/22/2025 showed that the sections for the resident’s condition on discharge and prognosis on discharge were left blank. During interviews, the MR stated she was responsible for ensuring the doctor completed and signed the PDS form, the DP stated that monitoring completion of the PDS was the MR’s responsibility, and the DON stated the MR should have obtained the doctor’s note for the resident’s condition and prognosis before the physician signed the PDS. The DON also stated a licensed nurse was responsible for verifying with the doctor that the discharge document was complete at the time of discharge to home. The facility policy titled Transfer or Discharge, Facility-Initiated stated that the resident’s medical record should include documentation by the attending physician and a summary of the resident’s overall medical, physical, and mental condition.
Room Exceeded Allowed Resident Capacity
Penalty
Summary
The facility failed to ensure that one resident room accommodated no more than four residents. During observation, room [ROOM NUMBER] was seen with 5 beds and all 5 beds occupied. A review of the facility's room waiver dated 2/4/2026 showed that room [ROOM NUMBER] was 511 square feet and contained 5 beds. During interviews, LVN 1, CNA 3, and CNA 4 each stated that the resident rooms had enough space for staff to provide care safely and for residents to move around safely. The Administrator acknowledged that room [ROOM NUMBER] had 5 beds and 5 residents and stated that the room did not meet the requirement of only 4 residents in one room. A later review of the facility's room waiver letter dated 4/6/2026 showed a request for continued waiver for square footage per resident, with the facility stating that room assignments were reviewed during admission and checked frequently for appropriateness.
Insufficient Square Footage in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure 14 of 24 resident rooms—rooms 108, 109, 110, 111, 112, 114, 200, 201, 202, 203, 204, 206, 211, and 215—met the required square footage of 80 square feet per resident in multiple resident rooms. During observation on 2/4/2026 from 10:00 AM to 1:00 PM, these rooms were identified as not meeting the minimum space requirement, although the residents in the rooms were able to ambulate and/or move around in their wheelchairs freely and staff were observed to have enough space to provide care and place beds, side tables, dressers, and other medical equipment. A review of the facility’s room waiver dated 2/4/2026 showed that the rooms with 2 beds were described as being in accordance with resident needs and not having adverse effects on resident health and safety. The waiver listed room square footage ranging from 155.4 to 159.33 square feet for the affected 2-bed rooms, while the minimum square footage for a 2-bedroom was 160 square feet. During interviews, an LVN, two CNAs, and the Administrator stated that the rooms had enough space for residents to move around and for staff to provide care safely. The Administrator also stated that the facility would continue to apply for the room waiver for these rooms, and residents interviewed did not express concerns about room size.
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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What surveyors actually found near you
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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 | ★★★★★ | 38 | 1 |
| Ivy Creek Healthcare & Wellness Centre | 0.6 mi | ★★★★★ | 13 | 0 |
| San Gabriel Valley Medical Ctr D/p Snf | 0.6 mi | ★★★★★ | 17 | 0 |
| Royal Vista Care Center | 0.6 mi | ★★★★★ | 31 | 0 |
| Pine Grove Healthcare & Wellness Centre, Lp | 0.7 mi | ★★★★★ | 18 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.