Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Nursing & Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that front lobby restrooms and a utility hallway were not maintained free of accident hazards. The women’s restroom was open and accessible to residents but lacked grab bars, had no call system, and used an interior latch that prevented staff from opening the door from the outside, with the door also difficult to open from inside. The men’s restroom was similarly open and accessible and, although it had grab bars, it lacked any means for a resident to call for assistance. In addition, an unlocked room off a utility hallway accessible from a resident hallway contained biohazard containers filled with used syringes, contrary to the facility’s own environment and safety policy.
A resident with COPD, diabetes, and fibromyalgia, who was cognitively intact, had a care plan and facility policy requiring that the call light be kept within reach. During observation, the call light was not visible and was found wound around the call light box, and the resident reported not having or knowing the location of the call light. A CNA stated she had wound the cord around the box while making the bed and likely forgot to return it to the resident’s reach, and an LVN confirmed the call light was out of reach and that leaving a resident without a call light was not normal practice and could pose potential harm in an emergency.
A resident with intact cognition, multiple chronic conditions, and a Foley catheter for bladder management was receiving catheter and incontinent care from two CNAs when the privacy curtain at the end of the bed was not fully closed, leaving the resident’s genitals exposed and visible to anyone entering the room. The resident’s MDS documented frequent incontinence, and the care plan addressed Foley catheter care and monitoring for UTI. Both CNAs later acknowledged that the curtain should have been closed, and facility leadership confirmed that resident rights training had been provided and that policy requires privacy and confidentiality during care.
A resident with severe cognitive impairment and multiple psychiatric diagnoses had a PRN order for ABH gel (Ativan/Benadryl/Haldol) written to be applied transdermally every 8 hours as needed for anxiety, agitation, or restlessness, but the order lacked a required 14-day stop date. The DON acknowledged that ABH gel is a psychotropic medication and that PRN psychotropic orders should not exceed 14 days, and facility policy required Medical Records to verify that physician orders are complete and accurate. This failure to time-limit the PRN psychotropic order resulted in a cited deficiency.
A resident with COPD, diabetes, hypertension, and documented bilateral hearing impairment was admitted with hearing aids, as noted in hospital records and the admission MDS. However, the baseline care plan created within 48 hours of admission did not address the resident’s hearing deficit or use of hearing aids. Observation confirmed the resident wore hearing aids and he reported long-term use due to hearing loss. The MDS nurse and DON acknowledged that the baseline care plan was incomplete and did not include all necessary information required by facility policy for proper, person-centered care.
A resident with an indwelling Foley catheter, diabetes, dementia, and other comorbidities was observed receiving perineal and catheter care from CNAs. One CNA used a back-and-forth wiping motion instead of front-to-back and cleaned the penis from base to tip rather than tip to base, contrary to the resident’s care plan and facility policy, which required cleaning around the catheter insertion site and then from the tip of the penis down to the body. The CNA later acknowledged knowing the correct technique, and the DON and Administrator confirmed the proper method and that staff had been trained and competency-checked on incontinent care.
A resident with severe cognitive impairment and diagnoses including renal dialysis dependence, depression, and anxiety was found with a jar of Vicks on the bedside table, despite no physician order for the product and no order to self-administer medications. The resident reported that family had brought the Vicks and that no self-medication assessment had been done. An LVN and the DON confirmed the medication was left at the bedside without secure storage or a self-administration assessment, contrary to the facility’s medication storage policy requiring secure storage of medications.
A resident with intact cognition and multiple medical diagnoses had a personal refrigerator containing an unlabeled, undated container with visibly spoiled contents, which remained in place on repeat observation. The resident reported storing snacks but was unaware of the requirement to date items and did not know about the container. The assigned CNA and LVN both confirmed the presence of the unlabeled, undated food and gave differing or incomplete understandings of responsibility for checking personal refrigerators, while the DON stated that all staff, overseen by charge nurses, were responsible for weekly monitoring and for ensuring perishable items in residents’ refrigerators were labeled and dated per facility policy.
A resident with multiple comorbidities and an indwelling Foley catheter, placed on enhanced barrier precautions, received incontinent and catheter care during which CNAs did not follow required infection control practices. One CNA cleaned the resident’s buttocks and genital area and then handled a clean brief and pad without changing gloves or performing hand hygiene, and two CNAs provided catheter care without donning gowns despite posted enhanced barrier precaution signage and available PPE. Facility policies required gowns and gloves for high-contact care activities and hand hygiene after PPE removal. During the same episode of care, staff did not close the privacy curtain, leaving the naked resident potentially visible from the doorway while a roommate remained in the room.
Delayed Comprehensive Care Plan Conference: A resident with dementia and severe cognitive impairment did not have a comprehensive care plan completed within 7 days of the assessment, and the care plan conference was held 25 days later. The resident and representative were invited but did not attend, and the SW stated the delay was due to an oversight.
Surveyors found that multiple residents with dementia, behavioral disturbances, and schizoaffective disorder did not have required face-to-face physician visits documented over an extended period. Facility policy required the attending physician to evaluate residents at specified 30- and 60-day intervals and document these visits, but record review showed no physician progress notes or H&Ps authored by the physician for several residents. An NP completed assessments and H&Ps, with the physician signing but not dating at least one document, and the DON and ADM reported that the physician rounded weekly and signed NP notes, yet they could not produce any physician-written progress notes or H&Ps for the residents involved.
A resident with complex cardiopulmonary conditions had a critical CO2 lab value reported to an LVN, who documented that the NP and DON were informed but did not complete a change-of-condition assessment, did not document vital signs, and did not document any notification to the resident or the resident’s representative. Another LVN later phoned the NP about the critical lab but failed to document that contact. The DON and NP reported that the first LVN used unsecured text/email instead of required phone calls and did not follow established change-of-condition and notification protocols. The resident and the resident’s emergency contact stated they were never told about the abnormal lab result, leading to a deficiency for failure to promptly inform the resident, consult with the practitioner, and notify the resident’s representative of a significant change in condition.
An allegation of resident-to-resident abuse occurred when a cognitively impaired resident with dementia and a known history of throwing objects became upset during care and threw an empty plastic cup at a roommate who repeatedly opened the privacy curtain and made comments about the resident’s mother, causing a small skin tear over the roommate’s eyebrow that was treated on-site and followed by a room change. Despite facility policy and federal requirements mandating that alleged abuse be reported immediately but no later than 2 hours after suspicion, the ADM did not report the incident to authorities until the following day, exceeding the required timeframe and resulting in a deficiency for failure to timely report an alleged abuse incident.
A resident had a critical CO2 lab value, and nursing staff documented only that the NP and DON were informed and that the resident was stable, with no further detail on assessment or follow-up. An LVN later reported calling the NP and receiving no new orders but admitted forgetting to enter a progress note, and another LVN could not recall details of the critical lab or his documentation. The DON stated that an LVN reported assessing the resident and texting the NP and DON but did not document these actions. These omissions failed to meet the facility’s policy requiring detailed documentation of change in condition, provider notification, responses, and related care plan updates.
Two residents were not adequately protected from hazards due to lapses in supervision and environmental safety. One resident with a history of depression and suicidal ideation was able to access a razor and attempted self-injury after returning from a psychiatric hospitalization, without her care plan reflecting her increased risk or need for closer monitoring. Another resident with severe cognitive decline and a known risk for wandering was able to elope from the memory care unit due to ineffective preventive measures.
Two residents did not have their care plans updated by the interdisciplinary team after significant changes in their conditions. One resident's care plan lacked documentation of a history of suicidal ideation and a self-injury attempt, while another resident's care plan did not include the use of a geriatric chair for fall prevention, despite its use by staff. These omissions were confirmed through record reviews, staff interviews, and observations.
A resident who was discharged home with no cognitive impairment did not receive notification or a refund of over $1,000 in personal funds within 30 days, as required. The facility's business office was without a manager at the time, and the resident was unaware of the funds remaining in his account.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Two residents were referred to as 'feeders' by staff, indicating a failure to treat them with dignity and respect. This terminology was used by a MA and LVN during meal service, despite both having received training on resident rights. The DON confirmed that such language was not acceptable, as it did not align with the facility's policy on treating residents with respect and dignity.
The facility failed to obtain informed consent for the administration of Sertraline to two residents. One resident received the medication for several months without a valid consent, while another received it for over four months without any consent. The DON confirmed these oversights, which were against the facility's policy requiring informed consent for psychotropic medications.
The facility's kitchen failed to meet professional food service safety standards, with food boxes stored on the floor, frost and ice on freezer items, and an open jelly container left unrefrigerated. The Dietary Manager confirmed these oversights, which could risk foodborne illness for residents.
A facility failed to maintain proper infection control practices for two residents. An LVN did not wear a gown or gloves while performing an accu-check and administering medication to a resident under contact isolation precautions. Additionally, the LVN did not wear gloves during an accu-check for another resident with diabetes and a foot ulcer. The DON confirmed the need for PPE in these situations, highlighting a lapse in adherence to infection control policies.
The secure unit's lobby area in the facility was found to have a strong urine odor, creating an unpleasant environment for residents, staff, and visitors. Observations confirmed the odor, with no apparent cause identified, and residents appeared clean. LVN C and a frequent visitor acknowledged the smell, while the Housekeeping Supervisor was unaware but planned to address it. The facility's policy on minimizing institutional odors was not followed.
A facility failed to ensure a resident's OOH DNR order was completed and included in the medical record. The resident, with severe cognitive impairment and serious health conditions, was admitted with a DNR status, but the form was missing from the records. Interviews revealed the form might have been misplaced during a hospital transfer, contrary to facility policy requiring advance directives to be readily retrievable.
The facility failed to store controlled medications in a permanently affixed compartment in the A-Hall medication room. A miniature refrigerator contained a lock box with Morphine Sulfate, which was not permanently affixed and could be easily removed. The DON confirmed the oversight, and the facility's policy lacked guidance on permanent affixation, contrary to 42 CFR 483.45 (h)(2) requirements.
A resident's medical records were incomplete, missing documentation of two unwitnessed falls and behaviors requiring PRN medication. Despite facility policies, staff failed to document these incidents, hindering proper care and monitoring.
A resident with severe medical conditions was not monitored for side effects of Aspirin and Ticagrelor, antiplatelet medications, due to a lack of comprehensive care planning. Facility staff, including the LVN responsible for care plans and the DON, failed to include monitoring instructions in the care plan, despite the known risks of bleeding associated with these medications. This oversight was evident during an observation where the resident showed signs of potential bruising or bleeding.
The facility failed to ensure menus met residents' choices and did not have a method to inform them of menu substitutions, leading to dissatisfaction and poor intake. Multiple residents expressed concerns about food quality and lack of notification about changes, and grievances were submitted without noticeable improvements.
The facility failed to provide accessible call lights for two residents, one with severe cognitive impairment and another with moderate cognitive impairment. Both residents' call lights were out of reach, which was confirmed by staff and observed during a survey.
The facility failed to implement written policies and procedures to prevent abuse, neglect, and exploitation by not completing annual Employee Misconduct Registry searches for two staff members, LVN A and CNA B. The HRD and ADM, both new to their roles, discovered missing records and could not locate evidence of the 2023 searches, raising concerns about potential risks to residents.
Failure to Control Resident Access to Unsafe Restrooms and Biohazard Materials
Penalty
Summary
Surveyors identified that the facility failed to maintain resident-accessible areas as free from accident hazards as possible in the front lobby restrooms and a utility hallway. Observation of the women’s restroom in the front lobby showed it was open, unlocked, and accessible to residents, but lacked grab bars, had no means for a resident to call for assistance, and had an interior latch-type lock that could not be opened from the outside when engaged. The door was also difficult to open from the inside. Observation of the men’s restroom in the same area showed it was also open, unlocked, and accessible to residents, and while grab bars were present, there was no means for a resident to call for assistance. The Maintenance Assistant confirmed these conditions, acknowledged that residents might not be able to use the toilet safely without grab bars, would not be able to call for help if needed, and that staff would not be able to reach a resident if the women’s restroom door latch was engaged. Further observation in a utility hallway revealed a room without a doorknob or any means to lock it, which contained multiple stored items, including three containers labeled biohazard that held used syringes. The utility hallway was accessible from a resident hallway and could be reached by any ambulatory resident. The Maintenance Assistant confirmed that the biohazard containers with used syringes should not have been in an area accessible by residents. Review of the facility’s “Resident Rooms and Environment” policy, revised 08/2020, showed that the facility committed to providing a safe environment and ensuring that the physical layout does not pose a safety risk, which was not followed in these instances.
Call Light Not Kept Within Reach of Resident
Penalty
Summary
The facility failed to reasonably accommodate a resident’s needs by not keeping the call light within reach as required by the resident’s care plan and facility policy. The resident was an older adult female with COPD, diabetes, and fibromyalgia, and her admission MDS showed a BIMS score of 15, indicating she was cognitively intact. Her care plan, dated 3/11/2026, specified that the call light should be kept within her reach. During an observation of her room on 04/14/2026 at 10:30 AM, the call light was not visible, and further observation showed the call light cord was wound around the call light box rather than positioned for her use. The resident stated she did not have a call light and did not know where it was. In an interview at 10:35 AM, a CNA confirmed that the resident’s call light had been on the floor and that she had wound the call light cord around the call light box that morning when making the bed, acknowledging she probably forgot to leave it within the resident’s reach. At 11:00 AM, an LVN confirmed the call light was out of the resident’s reach and stated that it was not normal nursing practice for a resident to be left without a call light, noting that the absence of a call light could constitute potential harm if assistance was needed in an emergency. The DON later confirmed that the facility had a call light policy requiring call cords to be placed within residents’ reach and that the resident’s care plan addressed the need for a call light within reach.
Failure to Maintain Resident Privacy During Incontinent and Catheter Care
Penalty
Summary
The facility failed to ensure a resident’s right to personal privacy during the provision of incontinent and catheter care. A resident with diagnoses including Type 2 diabetes mellitus, dementia, major depressive disorder, and hyperlipidemia was admitted in 2025 with a readmission in early 2026. The resident’s Quarterly MDS showed a BIMS score of 14, indicating intact cognition, and documented that he was always incontinent of bladder and frequently incontinent of bowel. His care plan identified the presence of a Foley catheter to manage bladder function and included monitoring for signs and symptoms of urinary tract infection. On the observed date and time, CNAs D and E provided catheter and incontinent care to this resident without fully closing the privacy curtain at the end of the bed. As a result, the resident’s genitals were fully exposed and he could have been seen by anyone opening the room door. During subsequent interviews, both CNAs acknowledged that the privacy curtain had not been closed and stated it should have been, noting they had received resident rights training from the DON and ADON. The DON and Administrator confirmed that privacy must be provided during nursing care and that the curtain should have been completely closed, and facility policy on resident rights included the right to privacy and confidentiality.
Failure to Limit PRN Psychotropic Medication Order to 14 Days
Penalty
Summary
Surveyors identified that the facility failed to ensure a PRN psychotropic medication order was limited to fourteen days as required. Record review for Resident #5 showed an order summary with a start date of 04/09/2026 for ABH gel (Ativan/Benadryl/Haldol) 1-25-1, to be applied transdermally every 8 hours as needed for anxiety, agitation, or restlessness, but the order had no end date. Resident #5 had diagnoses including generalized anxiety disorder, major depressive disorder, psychotic disturbance, and altered mental status, and a quarterly MDS with a BIMS score of 0 indicating severe cognitive impairment; the care plan documented that the resident required psychotropic medications. During interview, the DON confirmed that ABH gel is a psychotropic medication and that a PRN order for it should have an end date of no more than fourteen days past the start date. The facility’s policy on physician orders stated that the Medical Records Department will verify that physician orders are complete, accurate, and clarified as necessary. This combination of an open-ended PRN psychotropic order, the resident’s severe cognitive impairment and psychiatric diagnoses, and the facility’s own acknowledgment and policy requirements formed the basis of the cited deficiency.
Failure to Include Hearing Needs in Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop and implement a complete baseline care plan within 48 hours of admission for a newly admitted male resident with diagnoses including COPD, diabetes mellitus, and hypertension. Record review showed that the resident’s hospital clinicals documented he was hearing impaired and wore bilateral hearing aids, and the admission MDS assessment also indicated the use of hearing aids under section D0300. Despite this information, the resident’s baseline care plan report, printed on the date of admission, did not include any care plan interventions or instructions addressing his hearing deficit or the use of hearing aids. Surveyor observation confirmed that the resident was wearing hearing aids in both ears, and in an interview he stated he had arrived at the facility with his hearing aids and had used them for years due to hearing loss. The MDS nurse stated that a baseline care plan should include anything a resident needs to receive proper care and acknowledged that the current care plan was insufficient for this resident. The DON, after reviewing the baseline care plan, stated that it should have contained additional information such as medications, transfer status, and therapy needs, and reported that insufficient care planning could result in residents not receiving proper care. The facility’s policy on comprehensive person-centered care planning required development of a person-centered base care plan for each resident within 48 hours of admission.
Improper Perineal and Catheter Care Technique for Male Resident
Penalty
Summary
The facility failed to ensure incontinent and catheter care were provided in accordance with appropriate treatment and service practices for one resident. The resident had diagnoses including type 2 diabetes mellitus, dementia, major depressive disorder, and hyperlipidemia, and was occasionally incontinent of bowel with an indwelling catheter. A quarterly MDS showed the resident had a BIMS score of 15, indicating no cognitive impairment. The resident’s care plan documented the presence of a Foley catheter to help manage bladder function and noted that the catheter required regular care to prevent infection, skin problems, or other complications, including monitoring and reporting signs and symptoms of UTI. During an observation of catheter and incontinent care, two CNAs provided care to the resident. While performing perineal and catheter care, one CNA used a back-and-forth wiping motion instead of a front-to-back motion and wiped the resident’s penis from the base to the tip instead of from the tip to the base. In a subsequent interview, the CNA acknowledged that the proper technique was front to back or tip to base and stated she did not realize she was using the wrong motion and that she had received incontinent care training within the year from the DON and ADON. The DON and Administrator confirmed in an interview that the correct motion to clean a resident was front to back to prevent contamination of the urinary tract and that staff received incontinent care training with annual skills checks. Facility policy for indwelling urinary catheter care for males specified washing around the catheter insertion site and then from the tip of the penis down to the body, which was not followed during the observed care.
Unsecured Bedside Medication Without Order or Self-Administration Assessment
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments and that only authorized personnel had access to medications, as evidenced by an unlabeled medication product being left at a resident’s bedside without a physician’s order or self-administration assessment. Record review showed that the resident, an older female admitted with dependence on renal dialysis, depression, and an anxiety disorder, had an admission MDS with a BIMS score of 3, indicating severe cognitive impairment. Review of the resident’s April 2026 physician orders revealed no order for Vicks VapoRub and no order permitting self-administration of medications. On observation, surveyors noted a jar of Vicks on the resident’s nightstand. In interview, the resident stated that her family had purchased and brought the Vicks to her over the weekend and confirmed that no one had conducted a self-medication assessment. LVN A, who was assigned to the resident, verified the presence of the Vicks jar on the bedside table and acknowledged that the resident had not been assessed for self-administration and should not have access to medications in this manner. The DON also confirmed that the jar of Vicks was found on the bedside table and stated that no medication should be left on a resident’s bedside table without a self-medication assessment. The facility’s “Medication Storage” policy, revised January 2026, required medications to be stored securely to prevent unauthorized access, diversion, loss, contamination, or misuse, which was not followed in this instance.
Failure to Monitor and Label Food in a Resident’s Personal Refrigerator
Penalty
Summary
The facility failed to ensure safe and sanitary storage of food items in a resident’s personal refrigerator, as required by its policy. Record review showed the resident had intact cognition with a BIMS score of 15 and diagnoses including Major Depressive Disorder, Hypertension, and Benign Prostatic Hyperplasia. During observations of the resident’s personal refrigerator, surveyors found an unlabeled, undated storage container with unidentified contents showing fuzzy, slimy patches in shades of green, black, and white. A subsequent observation shortly afterward confirmed the container remained in the refrigerator. In interviews, the resident stated he stored snacks in his personal refrigerator but was unaware that items had to be dated and was unaware of the unlabeled container. The CNA assigned to the resident confirmed the presence of the undated, unlabeled container and stated she did not know who was responsible for checking the resident’s personal refrigerator for expired food. The LVN assigned to the resident also confirmed the presence of the unlabeled, undated container and stated that all staff were responsible for removing such items from residents’ personal refrigerators weekly. The DON confirmed that perishable food and drinks in residents’ personal refrigerators should be labeled and dated, that all staff were responsible for removing undated and unlabeled food items weekly and assisting families with labeling and dating food brought in, and that charge nurses were responsible for overseeing this task in accordance with the facility’s “Personal Refrigerator” policy, which requires weekly monitoring of resident refrigerators.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Catheter and Incontinent Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program involving one resident with an indwelling Foley catheter who was on enhanced barrier precautions. The resident had multiple diagnoses including type 2 diabetes mellitus, dementia, major depressive disorder, and hyperlipidemia, and a quarterly MDS showed no cognitive impairment, occasional bowel incontinence, and use of an indwelling catheter. The resident’s care plan documented the need for Foley catheter care to prevent infection and related complications. During an observation of incontinent and catheter care, a CNA cleaned the resident’s buttocks and genital area and then handled a clean brief and pad without changing gloves or performing hand hygiene in between. The CNA later acknowledged she did not change gloves or sanitize her hands and stated she was nervous and forgot, despite having received infection control training within the year. In the same observation, two CNAs provided catheter care to the resident, who was on enhanced barrier precautions due to the indwelling catheter, without donning gowns before entering the room and performing care, even though enhanced barrier precaution signage was posted at the door and above the bed and PPE was available at the room entrance. Both CNAs stated they forgot the resident was on enhanced barrier precautions and confirmed they had received training on enhanced barrier precautions and had their skills checked. The facility’s policies on Standard and Enhanced Precautions and Hand Hygiene required use of gowns and gloves for high-contact care activities for residents on enhanced barrier precautions, including changing briefs and catheter care, and required hand hygiene after removing PPE. Additionally, during the observed care, the privacy curtain was not closed, and the resident was naked and could have been seen from the doorway while the roommate was present in the room watching television.
Delayed Comprehensive Care Plan Conference
Penalty
Summary
The facility failed to develop a comprehensive care plan within 7 days of completion of the comprehensive assessment for Resident #30, and the resident and the resident's representative were not involved within that timeframe. Resident #30 was admitted with diagnoses including dementia, hyperlipidemia, and secondary hypertension, and the admission MDS showed a BIMS score of 5, indicating severe cognitive impairment. The record showed the care plan conference note was dated 04/13/2026 and the conference was held on 04/15/2026, which was 25 days after completion of the comprehensive assessment. The resident and the resident's representative were invited but did not attend. During an interview on 04/17/2026, the Social Worker stated the care plan conference should have been held earlier and was not due to an oversight. The facility policy on Care Planning stated that the comprehensive care plan must be completed within 7 days after completion of the comprehensive admission assessment and prepared by the IDT team, including the resident and/or the resident's family or legal representative.
Failure to Ensure Required Physician Face-to-Face Visits and Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were seen face-to-face by a physician at the required intervals and that the physician documented these visits in the medical record, as required by facility policy. Surveyors determined that four residents did not have physician progress notes or history and physical (H&P) examinations completed by their physician for a one-year period. Facility policy dated 08/2020 required the attending physician to evaluate residents at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, with documentation of these visits in the health record. One affected resident had dementia with agitation and stimulant-induced anxiety disorder, a BIMS score of 8/15 indicating moderate cognitive impairment, and a care plan addressing cognitive impairment and behavioral issues such as throwing items at others, with interventions including monitoring behavior episodes and documenting potential causes. Another resident had unspecified dementia with behavioral disturbance and a care plan for impaired cognitive function, including using yes/no questions to determine needs. For this resident, an NP completed a history and physical, which was signed but not dated by the physician. A third resident had dementia with anxiety, a BIMS score of 15/15 indicating no cognitive impairment, and a care plan for impaired cognitive function with interventions such as identifying oneself at each interaction and maintaining eye contact. The fourth resident had schizoaffective disorder, bipolar type, with a BIMS score of 15/15 and a care plan for mood problems related to bipolar disorder, insomnia, depression, and anxiety, including risk for mood changes related to pain or discomfort and use of anticonvulsant medications for bipolar disorder. Review of the electronic health records for all four residents showed no physician progress notes, assessments, or H&Ps completed by their physician from 3/27/25 to 3/27/26. During interviews, the DON and ADM stated that the residents’ physician rounded on Wednesdays and signed off on NP notes, but they were unable to provide any written physician progress notes or H&Ps authored by the physician, other than the NP’s H&P for one resident that was signed but undated by the physician.
Failure to Notify Resident, Practitioner, and Representative of Critical CO2 Lab Result
Penalty
Summary
The deficiency involves the facility’s failure to immediately inform a resident, the resident’s practitioner, and the resident’s representative of a significant change in condition related to a critical laboratory result. The resident was admitted with multiple serious cardiopulmonary diagnoses, including heart failure, obstructive sleep apnea, chronic pulmonary edema, and acute and chronic respiratory failure with hypoxia. Her admission MDS showed a BIMS score of 15/15, indicating no cognitive impairment, and her care plan included monitoring for altered respiratory status and reporting signs and symptoms of respiratory distress to the physician as needed. A lab report dated 3/2/26 showed a critical CO2 value of 42 (reference range 21–31), flagged as a critical result, and documentation showed that LVN A was notified of this critical lab in the evening. In response to the critical lab, LVN A entered a progress note in the early morning hours stating that the resident had a critical CO2 result of 42, that the NP and DON were informed, and that the resident was stable at that time. However, there was no further documentation by LVN A describing a change of condition assessment, vital signs, or notification of the resident or her representative, and no change of condition assessment was found in the March assessments in response to the critical CO2 value. The DON later stated that LVN A had notified the NP and DON via text message rather than by phone, and that LVN A should have called the NP and DON for a critical lab, which was considered a change of condition, and should have contacted the on‑call nurse if unable to reach them. The NP reported that LVN A often did not follow protocols and that he texted her about the critical lab via his personal email, which she stated was not secure and violated HIPAA. On the following morning, LVN B documented that the night nurse had sent the results to the NP and was awaiting a response, and LVN B then called the NP to inform her of the critical CO2 value and the resident’s assessment. LVN B did not enter a progress note at that time and later stated she must have forgotten to document the call. When interviewed, the resident and her emergency contact both stated that facility staff had not notified them of any abnormal lab results, and the resident expressed that no one had talked to her about the abnormal lab and that she would have wanted the opportunity to decide whether to go to the hospital. Facility policy on change of condition required prompt notification of the attending physician and the resident or responsible party for significant changes, including serious abnormal labs, and required documentation of the time and method of physician contact and family notification. The survey findings showed that these notification and documentation requirements were not followed for this resident’s critical CO2 lab result. The facility’s own policy defined an acute change of condition as a clinically important deviation from baseline that, without intervention, may result in complications or death, and specified that serious abnormal labs required immediate physician notification, notification of nursing supervision, and prompt notification of the resident and responsible party. Interviews with LVN A confirmed his understanding that a critical lab was considered a change of condition, that he was required to assess the resident, obtain vitals, notify the NP and DON by phone, notify the resident’s representative, and document these actions, and that texting was not sufficient. Despite this, he could not recall what he did in response to this specific critical lab beyond the brief progress note, and there was no documentation that the resident or her emergency contact were informed. These actions and omissions led to the cited deficiency for failure to immediately inform the resident, consult with the physician, and notify the resident representative of a significant change in condition. The NP stated that when she was later contacted by LVN B, she understood the resident’s chronic hypercarbic respiratory failure and elevated CO2 levels and discussed that the resident was on oxygen and needed to be off due to CO2 retention. She noted that the resident was not in distress when assessed by LVN B and during her own rounding. However, the survey focused on the lack of timely, appropriate notification and documentation at the time the critical lab was first reported to LVN A, and on the resident and emergency contact’s report that they were not informed of the abnormal lab result. The combination of failure to follow the facility’s change of condition policy, failure to use appropriate communication methods with the NP and DON, failure to notify the resident and her representative, and incomplete documentation formed the basis of the deficiency.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure that an alleged incident of resident-to-resident abuse was reported to the appropriate authorities immediately, but no later than two hours after the allegation was made, as required by regulation and facility policy. Resident #2, who had dementia with agitation, moderate cognitive impairment (BIMS 8/15), anxiety, and a care plan noting behavior problems related to throwing items at other people, threw an empty plastic cup at his roommate, Resident #3, during care on 1/6/26 at 5:45 PM. The incident occurred when Resident #3 attempted to open the privacy curtain while staff were providing care to Resident #2, after having opened the curtain a couple of times before and making comments about Resident #2's mother. The cup struck Resident #3 and caused a small skin tear over his left eyebrow, which was treated in-house, and Resident #3 was subsequently moved to another room. The Provider Investigation Report showed that the Administrator (ADM) did not report this resident-to-resident altercation to the state survey agency until 1/7/26 at 11:04 AM, more than two hours after the allegation and outside the timeframe required for alleged abuse. The facility’s Abuse Prevention and Prohibition Program policy required that allegations involving abuse or resulting in serious bodily injury be reported immediately, but no later than two hours after forming the suspicion, to the state survey agency and other appropriate entities. During interview, the ADM acknowledged reporting the incident within 24 hours and stated she believed the two-hour requirement applied only when serious bodily injury occurred, characterizing the two-hour reporting requirement as a technicality. This failure to follow the regulatory and policy requirement for timely reporting of alleged abuse constituted the cited deficiency.
Failure to Document Nursing Response to Critical Lab Result
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident with a critical laboratory result. A progress note for this resident documented a critical CO2 value of 42 (reference range 21–31) and stated that the NP and DON were informed and that the resident was stable at that time. A subsequent note recorded that the night nurse (LVN A) reported sending the results to the NP and was awaiting a response. However, there was no further documentation by LVN A describing his assessment of the resident, any follow-up actions taken, or additional communication with the NP beyond this brief entry. Record review showed there was no change of condition assessment completed in response to the critical CO2 lab value. LVN B reported in interview that she called the NP around breakfast time regarding the critical lab and that the NP did not provide new orders, but she acknowledged she did not enter a progress note and stated she must have forgotten to document the contact and outcome. LVN A, in a telephone interview, did not remember details about receiving the critical lab or whether he wrote any notes. The DON stated that LVN A told him he had assessed the resident, found her stable, and texted the NP and the DON, but acknowledged he did not document these actions. These omissions were inconsistent with the facility’s Change of Condition Notification policy, which requires licensed nurses to document the date, time, and details of the incident and assessment, the time and method of physician contact, the response and any orders, family notification, care plan updates, and inclusion of the incident in the 24-hour report.
Failure to Prevent Resident Self-Harm and Elopement Due to Inadequate Supervision and Environmental Controls
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident, with a history of depression, anxiety, and a prior hospitalization for suicidal ideation, was able to access a shaving razor and attempted to injure herself by cutting her wrist. Despite her previous hospitalization for suicidal ideation and recommendations from a hospital psychiatrist for closer observation or placement in a secure unit, the resident was returned to the general population without enhanced supervision or environmental controls to prevent self-harm. The care plan did not reflect her history of suicidal ideation or the need for increased supervision, and there was no documentation of interventions specifically addressing her risk for self-injury after her return from the hospital. Staff interviews revealed that the resident's mood and behavior changes were known, and some staff expressed concerns about her safety and the appropriateness of her placement outside of a secure unit. The resident was able to obtain a razor, possibly from personal items brought in by family or from an unlocked utility room containing razors and other potentially hazardous items. The facility's policies required incident reporting for self-inflicted injuries and suicide attempts, but the administrator initially did not believe the incident required reporting. The environment was not adequately controlled to prevent access to dangerous items, and staff supervision and monitoring were insufficient to prevent the resident's self-injury. In a separate incident, another resident with severe cognitive decline and a history of wandering and exit-seeking behavior eloped from the memory care unit. The baseline care plan documented the resident's risk for elopement, but effective measures were not implemented to prevent the resident from leaving the secure area. These failures in supervision and environmental safety placed residents at risk for harm and resulted in the identification of Immediate Jeopardy by surveyors.
Failure to Update and Revise Care Plans Following Significant Changes
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments, to reflect the current condition of two residents. For one resident with a history of cerebral infarction, anxiety disorder, hemiplegia, and depression, the care plan did not include documentation of a hospitalization for suicidal ideation or a subsequent attempt to injure herself. Despite clear evidence in the medical record and psychiatric evaluation indicating the resident's risk for self-harm and recommendations for closer observation, the care plan was not updated to reflect these significant events or the recommended interventions. Another resident, diagnosed with Alzheimer's disease, dementia, high blood pressure, and anxiety disorder, experienced a significant decline and multiple falls. Although the resident was provided with a geriatric chair by hospice as a fall prevention measure after a hospital visit, this intervention was not added to the care plan. Staff interviews confirmed the use of the geriatric chair for fall prevention, but the care plan only reflected other interventions such as being up at the nurses’ station when anxious and scheduled care planning with family and hospice. The omission of the geriatric chair as an intervention was acknowledged by the MDS nurse, who could not provide a reason for its absence from the care plan. The facility’s policy required that care plans be reviewed and revised upon any status change, with the interdisciplinary team collaborating on intervention options and updating the care plan accordingly. However, in both cases, the care plans were not updated to reflect significant changes in the residents’ conditions or the interventions being used, as evidenced by record reviews, staff interviews, and direct observations.
Failure to Timely Convey Resident Personal Funds After Discharge
Penalty
Summary
The facility failed to convey a resident's personal funds within 30 days of discharge, as required. Record review showed that a male resident, who was cognitively intact at the time of discharge, had a positive balance of $1,030.01 in his personal funds account due to a Social Security deposit. The discharge was processed and accepted by the state, and the resident's account should have been closed with a refund issued within the required timeframe. However, the refund was not processed, and the resident was not notified of the remaining funds in his account. Interviews revealed that the Business Office Manager position was vacant at the time of the survey due to the sudden death of the previous manager. The administrator, who was not in position at the time of the resident's discharge, confirmed that the refund should have been processed but was unsure why it had not occurred. The resident reported being unaware of the funds and stated that he had not been informed by the facility about the deposit after his discharge.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to treat residents with respect and dignity, specifically in the case of two residents who were referred to as 'feeders' by staff members. This terminology was used by a Medical Assistant (MA) and a Licensed Vocational Nurse (LVN) when discussing the residents' needs for assistance during meals. The term 'feeders' was used to describe residents who required help with eating, which was observed during a meal service where a Certified Nursing Assistant (CNA) was assisting these residents. The use of this term was confirmed during interviews with the MA and LVN, who both acknowledged referring to residents in this manner. The deficiency was identified through observations, interviews, and record reviews, which revealed that the staff's language did not align with the facility's policy on resident rights and dignity. The Director of Nursing (DON) confirmed that referring to residents as 'feeders' was not acceptable and did not respect the individuality of the residents. Both the MA and LVN had received training on resident rights, yet the inappropriate terminology was still used, indicating a lapse in the application of this training. The facility's policy emphasizes treating residents with kindness, respect, and dignity, which was not upheld in this instance.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure informed consent for the administration of the psychotropic medication Sertraline for two residents. Resident #38, a man with intact cognition and diagnosed with depression, was prescribed Sertraline. Although verbal consent was reportedly obtained from the resident's representative, the consent was not signed by the LVN until several months later, rendering it invalid. The Director of Nursing (DON) confirmed that the consent process was not properly completed at the time the verbal consent was obtained. Resident #20, who has memory problems and was diagnosed with generalized anxiety disorder and major depressive disorder, was also prescribed Sertraline. The facility's records showed that the resident received the medication daily for over four months without informed consent being obtained. The DON acknowledged that this was an oversight and confirmed that the consent form was only created after a surveyor's intervention. The facility's policy requires that residents or their representatives be informed of the risks and alternatives to psychotropic medications, which was not adhered to in these cases.
Food Storage and Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. Boxes of food were improperly stored on the floor in the dry goods pantry, which was confirmed by the Dietary Manager. The manager explained that a recent delivery had not been properly stored due to time constraints. Additionally, frost and ice were found to have accumulated on two boxes of food in the freezer, which the Dietary Manager acknowledged could lead to potential contamination of the food items. Furthermore, an open container of jelly, which was labeled to be refrigerated after opening, was left out on the kitchen counter instead of being stored in the refrigerator. The Dietary Manager confirmed this oversight and stated that all dietary staff are responsible for ensuring proper storage of food items. These deficiencies were identified as potential risks for foodborne illness among residents receiving meals and snacks from the kitchen.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN A in handling two residents under specific care precautions. Resident #45, a man with paraplegia, a stage 4 pressure ulcer, and diabetes, was placed under contact isolation precautions due to his chronic wound and indwelling catheter. Despite the presence of a contact precautions sign and available personal protective equipment (PPE) outside the resident's room, LVN A entered the room without wearing a gown or gloves. She performed an accu-check and administered insulin and oral medications without adhering to the required contact precautions, which included wearing a gown and gloves. Similarly, LVN A did not wear gloves while performing an accu-check on Resident #23, a 65-year-old man with type 2 diabetes and a foot ulcer. LVN A stated that she typically does not wear gloves for accu-checks unless the resident has a condition like AIDS, which was not the case for Resident #23. This practice was contrary to the facility's policy, which mandates the use of gloves when there is a possibility of contact with blood or body fluids. The Director of Nursing (DON) confirmed that Resident #45 was under contact precautions and that all staff were required to wear gowns and gloves when entering his room. The DON also stated that gloves should be worn whenever there is a potential for contact with blood or body fluids, including during accu-checks. Despite having received training in infection control, LVN A did not follow the facility's policies, leading to the identified deficiencies in infection control practices.
Unpleasant Odor in Secure Unit Lobby
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in the secure unit's lobby area, which was found to have a strong smell of urine. This observation was made on January 24, 2025, at 10:32 a.m., with no obvious cause for the odor identified. Residents in the unit appeared clean and well-groomed, with no personal odors detected. LVN C confirmed the presence of the unpleasant smell, noting it created an uncomfortable environment for both staff and residents. A visitor, who frequents the facility approximately five days a week, also reported that the lobby area typically had an unpleasant odor. The Housekeeping Supervisor was unaware of the issue but stated she would inspect and clean the area. The facility's policy on maintaining a homelike environment, revised in February 2021, emphasizes minimizing institutional odors, which was not adhered to in this instance.
Failure to Maintain Resident's Advance Directive in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's advance directive, specifically an Out of Hospital Do Not Resuscitate (OOH DNR) order, was completed and included in the resident's medical record. The resident, an elderly woman with severe cognitive impairment and multiple serious health conditions, was admitted with a DNR status indicated on her profile. However, the facility did not have a copy of the DNR form in the electronic health record or any other files, which was confirmed through interviews with the social worker, Director of Nursing (DON), and MDS coordinator. The absence of the DNR form was attributed to a possible oversight during the resident's transfer to the hospital, where the form might have been included in the transfer packet without a copy being retained at the facility. This oversight was contrary to the facility's policy, which requires that copies of advance directives be maintained in the resident's medical record and be readily retrievable by staff. The failure to have the DNR form on file could lead to confusion regarding the resident's end-of-life wishes.
Failure to Properly Store Controlled Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments as required, specifically in the A-Hall medication room. During an observation, it was noted that controlled medications were not kept in a separate, permanently affixed compartment. A miniature refrigerator with a locked padlock was found to contain a small red lock box with Morphine Sulfate 100mg containers. Although the lock box was locked, it was not permanently affixed inside the refrigerator and could be easily removed. The Director of Nursing (DON) confirmed during an interview that the lock box containing controlled medications was not permanently affixed, but believed that the double locking mechanism met the requirements. The facility's policy on controlled substances did not include information about the need for controlled medications to be stored in a permanently affixed compartment. A review of the Regulation Text for 42 CFR 483.45 (h)(2) indicated that controlled drugs must be stored in separately locked, permanently affixed compartments, which the facility failed to comply with.
Deficiency in Medical Record Documentation for Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for Resident #4, as required by professional standards. Specifically, the electronic medical record (EMR) did not reflect two unwitnessed falls that occurred on separate occasions. The first incident involved the resident being found lying on the floor beside the bed, and the second incident occurred when the resident was found on the floor after being placed in a chair by a hospice CNA. Despite these falls, there was no documentation in the progress notes regarding these incidents, which is a critical oversight as it prevents staff from being fully informed about the resident's condition and necessary interventions. Additionally, the facility did not document behaviors that warranted the administration of PRN medications for Resident #4. On two occasions, PRN lorazepam and Ativan/Benadryl topical gel were administered without corresponding documentation of the behaviors that necessitated these medications. This lack of documentation is problematic as it hinders the ability of healthcare providers to monitor the resident's condition and the effectiveness of the medication, potentially leading to inappropriate care. Interviews with facility staff, including LVNs and the DON, revealed that there was an expectation for documentation of falls and behaviors requiring PRN medication. However, this expectation was not met, as evidenced by the absence of progress notes and behavior documentation. The DON and other staff acknowledged the importance of such documentation for ensuring accurate resident care and monitoring, yet the oversight persisted, indicating a lapse in adherence to facility policies and procedures.
Failure to Monitor Antiplatelet Medication Side Effects
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically regarding the monitoring of side effects from the use of Aspirin and Ticagrelor, both antiplatelet medications. The resident, who had a history of severe medical conditions including Nontraumatic Acute Subdural Hemorrhage, Major Depressive Disorder, Atherosclerotic Heart Disease, Myocardial Infarction, Hypertension, and Alzheimer's Disease, was not monitored for potential side effects of these medications, which could include significant bleeding. This oversight was identified during a review of the resident's care plan, which did not include any directives for monitoring side effects despite the known risks associated with these medications. Interviews with facility staff revealed a lack of understanding and communication regarding the necessity of monitoring for side effects of antiplatelet medications. LVN B, responsible for the nursing care plans, acknowledged that monitoring for bleeding was not included in the care plan and expressed uncertainty about how such monitoring would be documented. The Director of Nursing (DON) also admitted that the omission of monitoring in the care plan did not stand out during audits, indicating a gap in the facility's care planning process. The deficiency was further highlighted by the resident's condition during an observation, where purple discoloration was noted on various parts of the body, suggesting potential bruising or bleeding. Despite the facility's policy requiring comprehensive, person-centered care plans developed by an interdisciplinary team, the lack of specific monitoring instructions for the resident's antiplatelet medications posed a risk for delayed interventions and potential health decline.
Failure to Inform Residents of Menu Substitutions
Penalty
Summary
The facility failed to ensure that menus were developed and prepared to meet the residents' choices, including their nutritional, religious, cultural, and ethnic needs, while using established national guidelines. The facility did not have a method to inform residents of substitutions to the menu, which could lead to dissatisfaction, poor intake, and diminished quality of life. Record reviews and interviews revealed that residents were not notified of menu changes, and the facility's dietary manager (DM) and administrator (ADM) had differing expectations regarding communication of these changes. The DM stated that substitutions were logged but not communicated to residents, while the ADM believed residents were informed via a whiteboard, which was not present during observation. Multiple residents expressed dissatisfaction with the food quality and lack of notification about menu changes, and grievances had been submitted without resulting in noticeable improvements. The facility's policy on nutritional procedures did not include information on informing residents about substitutions. This lack of communication and failure to meet residents' dietary needs and preferences led to the identified deficiency.
Failure to Provide Accessible Call Lights
Penalty
Summary
The facility failed to provide reasonable accommodation of resident needs for two residents regarding the accessibility of call lights. Resident #16, a severely cognitively impaired [AGE] year-old female with chronic kidney disease, muscle weakness, cognitive communication deficit, and muscle wasting and atrophy, had her call light hanging over the headboard of her bed, out of her reach. This was observed on 02/21/2024 at 2:50 pm. A Certified Medication Aide (CMA) confirmed that the call light should not be over the headboard and acknowledged that the resident could not reach it. Similarly, Resident #17, a moderately cognitively intact [AGE] year-old female with senile degeneration of the brain, cognitive communication deficit, and cerebral infarction, had her call light on the floor under her bed, out of her reach. This was observed on 02/21/2024 at 2:54 pm. The resident confirmed she could not reach the call light, and the CMA and Licensed Vocational Nurse (LVN) both acknowledged that the call light should be within reach. The Director of Nursing (DON) also stated that call lights should be accessible to residents to request assistance, as per the facility's policy dated 09/2022.
Failure to Implement Annual Employee Misconduct Registry Searches
Penalty
Summary
The facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for two staff members, LVN A and CNA B, by not completing an annual Employee Misconduct Registry (EMR) search. The last EMR search for LVN A was completed on 02/11/2022, and for CNA B on 01/21/2022. The facility's Abuse and Neglect policy, revised in April 2021, mandates conducting employee background checks and not employing individuals with findings of abuse, neglect, or exploitation. However, no evidence of completed recurring searches of the EMR was found within the facility policy. The HRD, who started in January 2024, discovered many personnel records were missing or misplaced and could not locate evidence of the 2023 EMR searches for LVN A and CNA B. The ADM, also new to the role as of January 2024, was unaware of the annual EMR searches for these staff members and stated it was the HRD's responsibility to ensure these checks were completed annually. Interviews with the HRD and ADM revealed that the previous HRD had informed them that EMR searches were completed in 2023, but no evidence could be found to support this claim. The HRD acknowledged her role in ensuring staff were searched for employee misconduct but could not correct past mistakes. The ADM expressed her expectation that all staff be searched annually in the EMR, including existing staff before her tenure. The lack of evidence for the annual EMR searches for LVN A and CNA B raised concerns about the potential risk to residents, as they could be cared for by staff who had committed misconduct towards residents in long-term care.
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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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Nursing homes near San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sage Park San Antonio | 1.1 mi | ★★★★★ | 15 | 0 |
| Northeast Rehabilitation And Healthcare Center | 2.7 mi | ★★★★★ | 10 | 1 |
| The Village At Incarnate Word | 2.9 mi | ★★★★★ | 8 | 0 |
| Castle Hills Rehabilitation And Care Center | 2.9 mi | ★★★★★ | 52 | 1 |
| Parklane West Healthcare Center | 3.6 mi | ★★★★★ | 13 | 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.