Below 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 Manor Care Center during CMS and state inspections, most recent first.
Failure to Notify MD of Arm Swelling and Discoloration A resident with a hx of a displaced R humerus fx, osteoporosis, and dementia developed swelling and discoloration of the R upper arm, but the physician was not clearly notified or informed of the change in condition. Documentation showed a VM was left, yet there was no record of the MD being told about the discoloration or of any response/order at that time. The resident later had an X-ray showing a displaced humeral fx and was transferred to acute care, while the facility had continued RNS and Hoyer lift-assisted care before the fracture was identified.
Failure to Develop Resident-Specific Care Plans for Dementia and Self-Inflicted Wound: The facility did not have comprehensive, person-centered care plans for two residents with dementia and one resident with a self-inflicted hand wound. One resident had confusion, irritability, refusal of ADL help, and safety concerns; another had dementia with confusion and agitation; and the third was observed picking at his nails and skin, with staff noting bleeding and no wound care plan in the record. Staff confirmed the missing dementia and wound care plans, despite the facility policy requiring measurable, individualized care plans for each resident.
Controlled medication handling and administration errors were observed in the facility. Two e-KITs containing lorazepam were not reconciled at shift change, a dose of modafinil for a resident was missing from the accountability record and bubble pack, and four medication disposition logs lacked witness initials for destroyed meds. In addition, an LPN applied lidocaine patches to both flanks even though the order specified two patches to the left flank area.
An open Lantus Solostar insulin pen for a resident was found on a med cart at room temperature without an opening date, and staff stated the pen should be dated and discarded 28 days after first use. In addition, an unopened box of Refresh eye drops was found in med room stock after its expiration date, and RN and DON acknowledged it should have been removed from use. Facility policy required expired meds to be separated and multi-dose containers to be dated when opened.
Improper Glove Use During Food Service: During a tray line observation, a Dietary Aide wore gloves while serving food, opened the refrigerator, handled a box, and then continued serving a bread roll with the same gloves. The RD observed the action and directed the aide to wash hands and change gloves. The DSD stated the aide should have washed hands and changed gloves before continuing food service, and the facility policy required disposable gloves to be discarded after each use or when soiled.
Insufficient CNA Training and Competency for Weight Assessment: The facility failed to provide a sufficient training program to ensure CNA competence in weight assessment. The DSD stated CNAs weighed residents but had not been trained on weight assessment and there was no competency checklist for it. An RNA could not recall the last training on weighing residents, and an RN stated a resident was weighed monthly only instead of weekly for the first month after admission. The annual education calendar and CNA competency checklist did not include weight assessment, even though the facility policy required training before staff provided services and annually as needed.
A resident with dementia, psychosis, and HF had an Advance Directive acknowledged in the chart and referenced in the POLST, but surveyors found no copy of the document in either the electronic or physical record. The MDS indicated the resident could not complete the BIMS and had severely impaired decision-making, while the FM stated she had provided the document on admission. The ADON confirmed the document was not located, and the SSD said she was unaware it was missing until the survey review.
Crushed medications were combined before administration. An LVN crushed Amlodipine, Benztropine, and Docusate, then opened Gabapentin and mixed all four meds together with applesauce for one resident before the surveyor stopped the administration. The resident had Parkinson’s disease, neuropathy, hypertension, and respiratory failure. The LVN and DON both stated crushed meds should be prepared separately, and the facility P&P said crushed medications should not be combined and given all at once.
A resident with rheumatoid arthritis, PVD, and bipolar disorder refused ROM exercises and hand roll splints, and the RNA program was discontinued after the refusals. The care plan called for monitoring stiffness and using pillows or splints as needed, but OT noted the resident was refusing passive ROM and hand rolls, and the DON stated no alternative measures were provided and no assessment was done for the reason for refusal. The resident said she wanted to do simple preferred exercises and could move some extremities with assistance.
Missing Oxygen Precaution Sign: A resident receiving oxygen by nasal cannula was observed without an "Oxygen in Use" sign posted on the room door. The resident had diagnoses including Alzheimer's disease, Parkinson's disease, and schizophrenia, and was moderately impaired with thinking and memory. An LVN and the DON both stated that a sign should be posted whenever oxygen is in use, and the facility policy required an Oxygen in Use sign on the outside of the room entrance door.
Failure to Monitor Fluid Intake for a Dialysis Resident: A resident with ESRD on hemodialysis had an RD fluid requirement of 750 to 1500 mL, but staff did not monitor or document her fluid intake. Her orders only included no water pitcher at bedside, and CNAs and nurses were unable to state how much she drank. Observations showed cups of water at her bedside, while staff said they could not find a specific fluid restriction range in the orders or any EMR documentation of intake.
Inaccurate Monitoring and Documentation of Resident Food Intake: A CNA failed to demonstrate competency in accurately monitoring and documenting a resident’s meal intake for a resident on a renal 90 g CCHO diet with ESRD, DM, and hypothyroidism. Staff gave conflicting reports about how much the resident ate at breakfast and lunch, and the DSD stated the CNA had not been present for prior in-service training on nutritional and hydration needs.
A resident with major depressive disorder, chronic ataxia, and type 2 DM had upper and lower dentures documented on the inventory list and needed assistance with oral hygiene and denture use per the MDS. The family stated the resident had no teeth and used dentures, but CNA reported the dentures could not be found, and the resident was later observed eating lunch without them. The ADON stated staff should have placed an ID label on the dentures to help prevent loss or misplacement, and the facility policy required dentures to be protected from loss or damage while stored.
Incomplete Advance Directive and POLST Documentation: The facility failed to ensure complete medical record documentation for two residents. One resident’s Advance Directive Acknowledgement form lacked a date, despite records showing the resident had decision-making capacity, and another resident’s POLST was missing the required signature of the resident or legally recognized decision-maker. The DON, RN3, and SSD confirmed the documentation errors during record review.
Failure to document respiratory infection signs and symptoms occurred for a resident with dementia, encephalopathy, and a history of RSV. The resident was ordered to be monitored for COVID-related symptoms and to have daily temperature, pulse, and SpO2 checks, but the record showed a suspected respiratory infection with cough and later monitoring for coughing with a new azithromycin order, while the MAR did not document any coughing episodes. The IP and DON stated a full set of vital signs, including temperature, should have been obtained and documented after the change in condition, consistent with the facility’s Infection Control policy.
Bedroom Space Requirements Not Met: The facility failed to ensure that multiple-occupancy resident rooms met the required square footage per resident. Surveyors found that most rooms reviewed did not meet the 80 sq. ft. per resident standard, with actual room sizes below the required amount for the number of beds and residents assigned. Although residents and staff stated there was enough space for care, mobility equipment, and transfers, the facility’s policy required at least 80 sq. ft. per resident in double rooms.
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 Right Arm Change in Condition
Penalty
Summary
The facility failed to assess and notify the physician when A resident had a change in condition involving the right upper arm on 5/9/2026. The resident’s record showed diagnoses including a displaced fracture of the greater tuberosity of the right humerus, osteoporosis, and dementia, and the MDS indicated functional limitation in ROM of both upper and lower extremities with dependence for shower/bath, dressing, and tub/shower transfer. On 5/9/2026, the resident was noted to have swelling and discoloration of the right anterior bicep/right upper arm, and a voice message was left for the attending physician, but there was no documentation that the physician was informed of the condition change or that the possible cause was discussed at that time. The hospice visit summary for the same day documented right arm swelling with edema, normal temperature, and no redness, but did not show that the physician was made aware or what response was received. The licensed nurse later stated she observed swelling, edema, and a light green discoloration on the resident’s right upper arm, but did not inform the physician about the discoloration and there was no documentation of the time of the call or any specific order received. The resident’s care plan for edema/swelling of the right arm was not developed until 5/12/2026, and the X-ray result on 5/13/2026 showed a displaced right humeral fracture, after which the resident was transferred to a GACH for evaluation. The report also states the facility continued restorative nursing services and assisted the resident out of bed via Hoyer lift transportation to shower on 5/11/2026 while the displaced fracture was present.
Failure to Develop Resident-Specific Care Plans for Dementia and Self-Inflicted Wound
Penalty
Summary
The facility failed to develop comprehensive, resident-specific care plans for three sampled residents in accordance with its care plan policy. Resident 4 was admitted with diagnoses including dementia, psychotic disturbance, and anxiety, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS indicated moderate cognitive impairment and dependence on staff for all ADLs. A CNA reported that Resident 4 had periods of confusion and forgetfulness, episodes of irritability, refusal of ADL assistance, safety concerns related to cognitive impairment, and an inability to use the call light. RN 1 stated there was no care plan specific to the resident’s dementia and associated behaviors. Resident 31 was admitted with diagnoses including dementia, depression, anxiety, and bipolar disorder. The MDS indicated an active diagnosis of dementia. LVN 1 stated Resident 31 was sometimes confused and agitated and confirmed that the medical record did not contain a dementia care plan. The ADON stated Resident 31 should have a care plan for dementia, and the MDS nurse stated dementia care plans were important to provide care for cognitive impairment and safety. The facility policy required the interdisciplinary team to develop and implement a comprehensive, person-centered care plan for each resident. Resident 8 was admitted and readmitted with diagnoses including major depressive disorder, chronic ataxia, and type 2 diabetes mellitus. The MDS indicated moderately impaired cognition. A Change of Condition/Interact Assessment documented a self-inflicted wound with minimal bleeding from nail and skin picking. Review of the medical record found no care plan to facilitate treatment and monitoring of the wound. During observation, Resident 8 was seen picking at his nails and skin using fingers on both hands. CNA 6 stated the resident picked his skin with his nails and fingers causing bleeding, and TN 1 stated there was no care plan for the wound and that it should include wound cleaning and monitoring for signs and symptoms of infection.
Controlled medication reconciliation, documentation, and administration errors
Penalty
Summary
The facility failed to reconcile two medication emergency kits containing lorazepam in Medication Room Station A for February 2026. During observation and interview, one e-KIT stored in the refrigerator and labeled REF493 and another e-KIT stored in a cabinet at room temperature and labeled 308 were both found without an accountability log showing controlled substance inventory reconciliation at each shift change. The Director of Nursing stated that these kits were not reconciled each shift and that consistent reconciliation was necessary to maintain accountability and prevent controlled substance diversion. The facility also failed to account for one dose of modafinil for a resident in Medication Cart 1. During observation, the bubble pack for modafinil showed 26 tablets remaining when the accountability log indicated 28 tablets should have been present, and there was no documentation of administration for the missing doses. The LVN stated that two modafinil 100 mg tablets had been administered that morning and that the controlled medication record had not been signed after the dose was given. The DON stated that the medication had not been documented timely on the accountability record, and the resident’s record showed modafinil 200 mg was ordered daily for sleep apnea. The facility further failed to include verifying witness initials on four Medication Disposition Record logs for medications destroyed on 1/19/2026. During record review and interview, RN 1, LVN 2, and the DON were unable to locate signatures, initials, or witness names on the logs, and the DON stated licensed nurses failed to include witness initials when destroying medications. In addition, during observation, an LVN applied lidocaine patches to both the right and left flank areas of a resident, even though the physician’s order specified two lidocaine 4% patches to the left flank area. The LVN acknowledged that the patches were applied contrary to the order, and the DON stated that both patches were not administered to the left flank area as ordered.
Unlabeled Insulin Pen and Expired Stock Medication
Penalty
Summary
The facility failed to label an open Lantus Solostar insulin pen for Resident 83 and failed to remove an expired Refresh eye drop medication from facility stock. During observation of Medication Cart 2, an open and used Lantus pen was found stored at room temperature without a date showing when it had first been opened or when room-temperature storage began. LVN 6 stated the pen should be stored at room temperature below 86 degrees Fahrenheit and used or discarded within 28 days of opening, but the opening date was unknown. During observation in Medication Room Station A, an unopened box of Refresh eye drops was found stored with other facility stock medications even though the box was labeled with an expiration date of 12/2025. RN 1 acknowledged that the eye drops had expired and should have been removed from use and placed in the expired medication bin to prevent accidental use. RN 1 also stated expired medications may have less or no potency and would not be effective when used for residents. The DON stated the Lantus pen was not labeled with the date it was first opened and that several LVNs failed to label it. The DON also stated several LVNs failed to remove expired Refresh eye drops from facility stock. Facility policy required expired or discontinued medications to be marked, stored separately, and removed from carts or storage areas prior to expiration, and required multi-dose containers to be dated when opened. The manufacturer guidance for Lantus stated the pen should be discarded after 28 days of first use.
Improper Glove Use During Food Service
Penalty
Summary
The facility failed to follow its Sanitation and Infection Control policy during a tray line observation when a Dietary Aide, while wearing gloves, opened the refrigerator door, removed a box, placed it on the counter, and then continued serving a bread roll with the same gloved hand. The Registered Dietitian who was present during the tray line observed the action and instructed the Dietary Aide to wash his hands and change to new gloves. During interview, the Dietary Supervisor stated the Dietary Aide should have washed his hands and changed gloves before continuing to serve food, and stated the practice could have placed residents, especially those who are immune compromised, at risk for food borne illness. The facility policy stated disposable gloves are to be worn for single use and discarded after each use or when soiled.
Insufficient CNA Training and Competency for Weight Assessment
Penalty
Summary
The facility failed to provide a sufficient training program to ensure the continuing competence of certified nursing assistants. During an interview, the DSD stated that nursing assistants weigh residents, but they were not given training on weight assessment and there was no competency tool checklist for weight assessment. The annual education calendar for 2025 did not include weight assessment topics, and the Certified Nursing Assistant Competency Evaluation Checklist dated 10/10/2025 did not include competency evaluation for weight assessment in the nursing assistant skills competency. During interviews, an RNA stated that nursing assistants do weigh residents but could not remember the last time training on weighing residents was provided. An RN stated that Resident 8 was weighed monthly only and was not weighed every week for the first month after admission. The ADON stated that nursing assistants provide care to residents and trainings should be provided for them to be competent on their job, and also stated that one of the nursing assistants' main tasks is to weigh residents upon admission, every week for the first month of admission, and monthly thereafter. The facility policy on in-service training stated that training requirements are met prior to staff providing services, annually, and as necessary based on the facility assessment.
Missing Advance Directive in Resident Record
Penalty
Summary
The facility failed to ensure that Resident 48 had a current and accessible copy of the Advance Directive in both the electronic chart and physical clinical record. Resident 48 was admitted to the facility with diagnoses including dementia, unspecified psychosis, and heart failure. The resident’s Advance Directive Acknowledgement form dated 9/30/2022 indicated that an Advance Directive was available and would be followed by the facility and caregivers to the extent permitted by law, and the POLST prepared by the facility on 8/17/2023 and signed by Family Member 1 on 10/10/2024 also indicated that an Advance Directive dated 12/14/2020 was available and reviewed by the facility. The MDS dated 1/1/2026 indicated Resident 48 was unable to complete the Brief Interview for Mental Status and had severely impaired cognitive skills for daily decision making, and it also indicated the Advance Directive was not available. Family Member 1 stated she had given the facility a copy of the Advance Directive when the resident was initially admitted. During review of the resident’s physical and electronic clinical chart, the ADON stated that a copy of the Advance Directive was not located in either record and did not know why it was missing. The SSD stated she was not aware the copy was not in the chart until the survey investigation and noted that having the document in the chart was important so facility staff, paramedics, and the hospital would be aware of the resident’s and representative party’s wishes.
Crushed medications were combined before administration
Penalty
Summary
The facility failed to provide medication administration in accordance with professional standards of quality and facility policy for one resident observed during morning medication pass. During observation, an LVN crushed Amlodipine 5 mg, Benztropine 3 mg, and Docusate 100 mg into a small plastic cup, then opened a Gabapentin 100 mg capsule and poured its contents on top of the crushed medications. The LVN added applesauce and mixed all four medications together before preparing to administer them to the resident. The surveyor stopped the LVN before any medication was given and the LVN stated that crushed medications should not be combined and should be prepared separately for administration. The resident had diagnoses including respiratory failure, Parkinson's disease, neuropathy, and hypertension. The MAR showed orders for Amlodipine once daily, Benztropine twice daily, Docusate once daily, and Gabapentin three times daily, and also included an order starting that day to crush medications, mix with applesauce or an alternative, and administer as a single oral bolus. During interview, the DON acknowledged that the order indicated a single oral bolus and stated that, as standard practice, crushed medications should be administered separately and not combined together. The facility P&P titled Medication Administration-General Guidelines stated that crushed medications should not be combined and given all at once, and the Crushing Medications policy stated that crushing each medication separately is considered best practice.
Failure to Address Refusal of ROM and Splint Use
Penalty
Summary
The facility failed to ensure that Resident 7, who had diagnoses including rheumatoid arthritis, PVD, and bipolar disorder, was assessed for refusal of care and provided alternative treatment and services when the resident refused ROM exercises and the use of hand roll splints. The resident’s MDS indicated no cognitive impairment, and the care plan for altered joint mobility called for monitoring pain or stiffness, providing therapy intervention as needed, and positioning with pillows or splints as needed to prevent further contractures and loss of ROM. Record review showed that Resident 7 continued to refuse bilateral upper extremity exercises despite education and encouragement, and later OT documentation stated that splints were not recommended due to flexion contractures, that the resident was refusing to wear hand rolls and passive ROM, and that the RNA program was discontinued because of the refusal to participate. During interviews, PT stated the resident refused splints and ROM exercises with the RNA, and the DON stated there were no alternative measures provided and no assessment for the reason for refusal. The resident stated she could move her arms and legs to some extent, wanted to do simple preferred exercises, and acknowledged her joint limitations.
Missing Oxygen Precaution Sign
Penalty
Summary
The facility failed to provide a safe, hazard-free environment when it did not display an "Oxygen in Use" precaution on the door for one resident who was receiving oxygen. During an initial tour on 2/9/2026 at 9:52 AM, the resident was observed lying in bed receiving oxygen at 4 liters via nasal cannula, and there was no sign on the room door indicating that oxygen was in use or that smoking was prohibited. The resident's record showed diagnoses including Alzheimer's disease, Parkinson's disease, and schizophrenia, and the MDS dated 1/22/2026 indicated the resident was moderately impaired with thinking and memory. The resident's physician orders dated 2/1/2026 included oxygen at 2 liters per minute via nasal cannula with titration up to 5 liters per minute for oxygen saturation below 90% as needed for shortness of breath and low oxygen saturation. During interview, an LVN stated that oxygen was on at 4 liters and that there should have been a sign on the resident's door to communicate that oxygen was in use. The DON also stated that whenever oxygen is in use, a sign should be posted at the entrance of the resident's room to alert everyone that oxygen is in use and to prevent fire and injury. The facility policy titled Oxygen Administration stated that the facility must place an Oxygen in Use sign on the outside of the room entrance door.
Failure to Monitor Fluid Intake for a Dialysis Resident
Penalty
Summary
The facility failed to ensure that Resident 2’s fluid intake was monitored and followed according to the Registered Dietitian’s fluid restriction recommendation of 750 to 1500 mL. Resident 2 was admitted with diagnoses including Type 2 DM, ESRD, and dependence on renal dialysis. Her care plans identified risks related to chronic anemia, altered fluid balance, and weight changes due to fluid retention secondary to ESRD and hemodialysis, and her history and physical indicated she had the capacity to understand and make decisions. Resident 2’s orders included a fluid restriction of no water pitcher at bedside, and her MDS indicated she received hemodialysis and needed assistance for meals. The RD nutritional assessments dated 8/6/2024, 7/9/2025, 9/29/2025, and 1/21/2026 documented a fluid requirement of 750 to 1500 mL. During observations, Resident 2 was seen with small plastic cups of water on her bedside table, including one half filled with water on 2/10/2026 and two cups of water 3/4 full on 2/12/2026. During interviews, CNA 4 and RNA 1 were unable to state how much fluid Resident 2 drank with meals, and CNA 4 stated she was unaware of any current residents on fluid restrictions. LVN 1 and RN 1 reviewed the orders and RD assessment and stated the only active fluid restriction order was no water pitcher at bedside, that they could not find a specific fluid restriction range in the orders, and that there was no documented evidence in the EMR showing how much fluid Resident 2 drank throughout the day. The facility policy stated nutritional assessment and resident care plan documentation would be entered into the medical record, and the RD would include estimation of nutritional intake and adequacy of intake.
Inaccurate Monitoring and Documentation of Resident Food Intake
Penalty
Summary
The facility failed to ensure that CNA 6 had the competency to accurately monitor and document the food intake of one resident who was receiving a renal diet. The resident was admitted and later readmitted with diagnoses including Type 2 DM, ESRD, and hypothyroidism. The resident’s HP indicated she had the capacity to understand and make decisions, and the MDS indicated her cognitive skills were intact, she needed assistance with meals, was always incontinent of bladder and bowel, received hemodialysis, and was on a therapeutic diet. The resident’s care plan identified risks related to hypoglycemia and hyperglycemia and included interventions to offer bedtime snacks and monitor and record food intake. Another care plan identified risk for weakness, shortness of breath, pale skin, or fatigue related to hypothyroidism and included monitoring the percentage of intake and appetite. The active order list showed the resident was on a renal 90 gram, consistent carbohydrate diet with regular texture and thin consistency. On the day of observation, CNA 4 stated the resident did not eat breakfast and did not know her fluid intake for breakfast, while RNA 2 later stated the resident ate about 80% of lunch and drank about 3/4 of a cup of milk. CNA 6 later stated the resident ate less than 50% of breakfast and 50% of lunch. The facility’s DSD stated inaccurate monitoring and documentation of food intake may lead to weight loss, especially for a resident receiving dialysis, and stated CNA 4 and CNA 6 were newly hired and were not present for the April 2025 in-service on nutritional and hydration needs.
Lost Dentures Not Protected From Misplacement
Penalty
Summary
The facility failed to provide care and services for one sampled resident with loss of dentures in accordance with its Dental Services policy. Resident 8’s face sheet listed diagnoses including major depressive disorder, chronic ataxia, and type 2 diabetes mellitus. The resident’s MDS dated 10/11/2025 indicated the resident needed supervision or touching assistance with oral hygiene and using dentures, and the resident’s inventory list dated 7/23/2025 documented upper and lower dentures signed and certified by the ADON. During interview, the resident’s family member stated that Resident 8 had no teeth and used upper and lower dentures. CNA 6 stated on 2/11/2026 that the resident’s upper and lower dentures were not in the room and could not be found. Later that day, the resident was observed eating lunch in the dining room without the upper and lower dentures. The ADON stated that the inventory list showed the resident had upper and lower dentures and that staff should have placed a resident identification label on the dentures to help prevent loss or misplacement. The facility policy stated that dentures would be protected from loss or damage to the extent practicable while being stored.
Incomplete Advance Directive and POLST Documentation
Penalty
Summary
The facility failed to ensure complete and accurate medical records for 2 of 8 sampled residents. For Resident 64, the admission record showed the resident was admitted on 09/07/2022 with diagnoses including acute respiratory failure, kidney failure, and atrial fibrillation. The H&P dated 1/23/26 indicated the resident had capacity to understand and make decisions, and the MDS dated 12/9/2025 indicated the resident was cognitively intact. However, the resident’s Advance Directive Acknowledgement form dated 06/16/2025 lacked a date indicating the resident was capable of making preferred intensity decisions. For Resident 42, the admission record showed admission on 1/28/2026 with diagnoses including UTI, adult failure to thrive, and dysphagia. The H&P dated 1/30/2026 indicated the resident was able to make decisions for ADLs, while the MDS dated 02/1/2026 indicated moderate cognitive impairment. The resident’s POLST dated 1/3/2025 did not contain the required signature of the resident or legally recognized decision-maker. During interviews and record review, the DON, RN3, and SSD confirmed the Advance Directive Acknowledgement form for Resident 64 was incomplete because it lacked a date, and Resident 42’s POLST was unsigned.
Failure to Document Respiratory Infection Signs and Symptoms
Penalty
Summary
Provide and implement an infection prevention and control program was deficient for one resident with dementia, encephalopathy, and a history of RSV. The resident’s record showed severe cognitive impairment and that the resident did not have the capacity to understand and make decisions. The resident’s order summary directed staff to monitor for signs and symptoms of COVID, including cough, shortness of breath, fatigue, chills, muscle or body aches, sore throat, loss of taste or smell, headache, congestion or runny nose, diarrhea, nausea/vomiting, and to document temperature, pulse, and pulse oximetry every day shift. The resident’s change-of-condition assessment on 2/9/2026 documented suspected respiratory infection with cough and recorded temperature, pulse oximetry, and heart rate, and a subsequent assessment on 2/10/2026 noted the resident was being monitored for coughing and had a new azithromycin order from the physician. However, the MAR for 2/9/2025 through 2/11/2026 did not document any episodes of coughing. During interview, the IP stated the resident should have had a complete set of vital signs, including temperature, heart rate, and pulse oximetry, after the change in condition to help prevent exposure of other residents and staff to respiratory infection, including COVID. The DON stated a temperature should have been obtained with a new onset of cough and that it was important to obtain a temperature reading to ensure an accurate report to the attending physician. The facility policy titled Infection Control stated the infection prevention and control program includes monitoring and documenting infections.
Bedroom Space Requirements Not Met
Penalty
Summary
The facility failed to ensure that resident bedrooms measured at least 80 square feet per resident in multiple-occupancy rooms, as required by its policy titled Bedrooms, dated May 2017. Surveyors found that 30 of 31 rooms, including Rooms 1-4, 6-12, and 4-32, did not meet the required square footage standards for the number of residents assigned to those rooms. A review of the facility’s request for an additional room size waiver, dated 2/9/2026, stated that each bathroom was easily accessible in the rooms and that there was sufficient room between beds and the foot of the beds to allow freedom of movement and transfers for wheelchair-bound residents. The Client Accommodation Analysis form submitted by the facility on 2/9/2026 listed multiple rooms with required square footage of 160 sq. ft. or 320 sq. ft., but actual room sizes ranged from 134.88 sq. ft. to 314.27 sq. ft., with room assignments including 1, 2, 3, or 4 residents in those rooms. During observations from 2/9/2026 to 2/12/2026, residents in Rooms 1-4, 6-12, and 4-32 were seen to have adequate room for wheelchairs, walkers, or canes, and staff were observed providing care without difficulty. Residents interviewed stated they were happy with the care and felt they had enough space in their rooms. CNA and LVN staff also stated there was adequate space to provide ADL care and that they had no difficulty providing care or transferring residents in the rooms. The facility’s policy still stated that bedrooms must measure at least 80 square feet of space per resident in double rooms.
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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Illustrative
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.
Illustrative
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Illustrative
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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 | ★★★★★ | 35 | 0 |
| Chestnut Ridge Post Acute Llc | 0.8 mi | ★★★★★ | 35 | 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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