Broadmoor Medical Lodge

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents who were incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 of 4 residents (Resident #1) reviewed for catheter care. The facility failed to ensure CNA A and the ADON place the catheter bag below bladder level while providing incontinent care. This failure could result in infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 1 of 4 residents (Resident #1) reviewed for infection control. The facility failed to ensure CNA A and the ADON performed hand hygiene in between glove changes while providing peri care for Resident #1. The facility failed to ensure CNA and the ADON placed Resident #1's catheter bag below bladder level while providing peri care. These failures could place residents at risk for infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident had a right to confidentiality of his or her personal and medical records for eight of eighteen residents (Residents #39, #73, #84, #98, #109, #125, #126, and #127) reviewed for privacy and confidentiality. The facility failed to ensure LVN E secured Residents #39, #73, #84, #98, #109, #125, #126, and #127's medical information before leaving her cart on 03/03/2026. This failure could place the residents at risk of their medical information being accessed by unauthorized individuals.

Inspectors wroteBased on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for three of eighteen residents (Residents #85, #89, And #128) and one LVN (LVN E) of three LVNs reviewed for medication storage. 1. The facility failed to ensure that Resident #85 did not have an eye drop inside the room on 03/03/2026. 2. The facility failed to ensure that Resident #89 did not have eye drops inside the room on 03/03/2026. 3. The facility failed to ensure that a skin barrier was not left on top of Resident #128's overbed table on 03/03/2026. 4. The facility failed to ensure LVN E did not leave a plastic vial of medication for breathing treatment on top of the nurse's cart unattended on 03/03/2026. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food storage, labeling, and dating. The facility failed to ensure all food items in the facility kitchen were dated and discarded prior to their use-by date . These failures could place residents at risk for food contamination and food-borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of eighteen residents (Resident #10, #18 and #93) and for six of eight direct care staff (RN B, RN C, CNA G, CNA H, CNA J, and COTA I) reviewed for infection control. 1. The facility failed to ensure RN B did not put the two cups of barrier cream she already placed on Resident #10's overbed table, inside the first drawer of her cart on 03/04/2026. 2. The facility failed to ensure CNA H did not put gloves inside her pockets and use them during Resident #18's incontinent care on 03/04/2026. 3. The facility failed to ensure CNA G wore a gown when shaving Resident #93 on 03/03/2026. 4. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for one of two residents (Residents #93) reviewed for feeding tube management. The facility failed to ensure Resident #93 had orders to flush the g-tube before and after medication administration, to check the placement, and to check the residual on 03/04/2026. These failures could place residents with g-tubes at risk for tube displacement, clogging, aspiration, and discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of twelve residents (Resident #6 and Resident #128) reviewed for respiratory care. 1. The facility failed to ensure Resident #6's Yankauer suction tip connected to the suction machine was properly stored on 03/03/2026. 2. The facility failed to ensure Resident #128's nasal cannula connected to the oxygen concentrator was properly stored on 03/03/2026. These failures could place the residents at risk of respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of two residents (Resident #9 and Resident #93) reviewed for dialysis. 1. The facility failed to ensure Resident #9 had orders for ongoing assessment of the resident's condition before and after dialysis treatments received at a certified dialysis facility. 2. The facility failed to ensure Resident #93 had orders for ongoing assessment of the resident's condition before and after dialysis treatments received at a certified dialysis facility. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals that met the needs of each resident for one of eighteen residents (Resident #126) reviewed for pharmaceutical services. The facility failed to ensure MA F did not leave Resident #126's medications inside the resident's room for the resident to administer unattended on 03/03/2026. This failure could place residents at risk of not receiving medications as ordered, taking medications without a self-administration assessment, potential overdose, and adverse effect.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for one of four direct care staff (RN C) reviewed for other environmental conditions. The facility failed to ensure that RN C did not leave a container of germicidal wipes on top of the nurse's cart unattended on 03/04/2026. This failure could result in having an environment that was not safe for the residents, staff, and public.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 3 of 15 residents (Residents #3, #4 and #5) reviewed for nutrition. 1. The facility did not ensure Resident #3 was given double protein portion as ordered by the physician. 2. The facility did not ensure Resident #4 was given ice cream and a shake as ordered by the physician. 3. The facility did not ensure Resident #5 was given a shake as ordered by the physician. These failures could place residents at risk for poor intake, weight loss, unmet nutritional needs, and a loss of dignity. Findings Included: 1. [...]

Inspectors wroteBased on interview and record review the facility failed to incorporate the recommendations from the PASARR Level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 2 residents (Resident #2) reviewed for PASARR. The facility failed to initiate an NFSS within 20 business days following the date the services were agreed upon in the IDT meeting. This failure could cause residents with mental health disorders and psychiatric conditions to have a delay in services or not receive specialized services or equipment that may be needed.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives through effective communication for 1 of 2 residents (Resident #1) reviewed for hospice services. The facility failed to communicate with hospice on 08/13/25 when Resident #1 fell, and on 10/17/25 when Resident #1 received bruises. This deficient practice could place residents who receive hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, and dispensing of routine drugs and biologicals to meet the needs of each resident for 4 of 4 resident reviewed for pharmacy services. (Resident's #5, #11, #49, and #50) The facility failed to ensure Resident #11's ordered alprazolam (antianxiety) medication was available for administration on 11/26/2024, 11/27/2024, 11/28/2024, and 11/29/2024, which resulted in 11 missed doses of her antianxiety medication. The facility failed to ensure Resident #50's ordered Letrozole (hormone treatment for breast cancer) medication was available for administration 12/03/2024. The facility failed to ensure Resident #49's tramadol (scheduled ll pain medication) was accurately reconciled on 12/03/2024. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 18 residents (Resident # 14) reviewed for MDS assessment accuracy. The facility failed to code Resident #14's hospice accurately. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on interview and record review the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 of 3 (Resident #49) residents reviewed for care plan revisions. The facility failed to revise Resident #49's care plan to remove her wound care when she no longer had a wound. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings Included: [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that the resident environment remained as free of accident hazards as possible for 1 of 18 Residents (Resident #37) reviewed for accidents and hazards. The facility failed to ensure Resident #37 had on her wander guard bracelet on 12/2/24 and 12/3/24. This failure could place residents at risk of elopement, injury, or harm.

Inspectors wroteBased on interview and record review, the facility failed to act upon the recommendations of the pharmacist report of irregularities for 1 of 5 residents (Resident #25) reviewed for (DRR) Drug Regimen Review. The facility failed to implement the pharmacy recommendations for Resident #25's medications that contained acetaminophen. This failure could place residents at risk for adverse side effects and not receiving medications at the most effective dosage.

Inspectors wroteBased on observation, interview, and record review, the facility failed store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 2 medication carts (Hall 300 nurse medication cart and 300 hall medication cart) of 6 medication carts reviewed for medication storage. The facility failed to ensure MA B secured a controlled narcotic medication when he left a Tramadol inside a medication cup sitting on the 300-hall medication cart when he walked to the nurse's station. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received therapeutic diets that were prescribed by the attending physician for 1 of 3 residents (Resident #49) reviewed for therapeutic diets. The facility did not ensure Resident #49 was given her ice cream as ordered by the physician. This failure could place residents at risk for poor intake, weight loss, unmet nutritional needs, and a loss of dignity. Findings Included: [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals for 1 resident reviewed (Resident #34) for special eating equipment and assistance when consuming meals. The facility failed to provide Resident #34's physician ordered plate guard. Thisese failures could place residents at risk for harm by weight loss, diminished independence, and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared and served in a manner that prevented foodborne illness for 1 of 1 kitchen reviewed for food preparation and serving. The facility did not ensure hair restraints were worn appropriately by the Dietary Manager. This failure could place residents who ate food from the kitchen at risk of foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 2 of 18 residents (Resident #14, and Resident #129) reviewed for hospice services. The facility failed to maintain Resident #14's, and Resident #129's hospice binder containing information related to hospice services provided for the resident such as the most recent plan of care, hospice election form, physician recertification, and hospice medication profile. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections reviewed for 2 of 18 residents (Resident #45, and Resident #49) reviewed for infection control. 1. The facility failed to ensure the Treatment Nurse performed hand hygiene while performing wound care for Resident #45 who had wounds, on 12/03/24. 2. The facility failed to ensure CNA S changed gloves or performed hand hygiene while providing incontinent care for Resident #49 who was incontinent, on 12/03/24. These failures could place residents, and staff at risk of the spread of infections.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, clean, comfortable and homelike environment allowing the resident to use his or her personal belongings to the extent possible for 1 of 1 shower reviewed for resident rights. The facility failed to ensure the shower did not have trash on the floor on 5/24/24. This failure could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 2 of 6 residents (Resident #1 and Resident #2) reviewed for baseline care plans. The facility failed to ensure Resident #1 and Resident #2 had baseline care plans completed within 48 hours of admission. This failure could place newly admitted residents at risk of receiving inadequate care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure food items in the refrigerator, freezer and dry storage room were labeled and stored in accordance with the professional standards for food service. 2. The facility failed to ensure the ice machine vent was free from greasy residue buildup with dust. 3. The facility failed to discard items stored in refrigerator, freezers or dry storage that were not properly labeled or past the 'best buy', consume by or expiration dates. 4. The facility failed to ensure the emergency water supply was monitored and changed out as needed 5. The facility failed to ensure handwashing sink #1 was free from debris in the sink. 6. [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 out of 4 residents reviewed. (Resident #133, Resident # 57, and Resident #33) The facility failed to develop person centered care plans for antibiotic use, medical management of seizure disorder, anxiety, depression and fall prevention for Resident #133. The facility failed to develop interventions/tasks within the person-centered care plans for hypothyroid disease, depression, malnutrition, and shortness of breath. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 (Hall 300) of 8 halls and 1(Nurses Station #1) of 2 nurses stations and one resident (#29) of 8 residents and one (confidential meeting) reviewed for Environment. The facility failed to repair or replace the flooring and carpet areas around the 300 hall and nurses' station #1, which was reported to the Maintenance Director months ago by staff and documented in the maintenance logbook. These failures placed residents at risk of being potentially at risk of tripping and falling which could cause injury, pain, and distress, resulting in a decrease in their quality of life and psycho-social well-being.

Inspectors wroteBased on interview, and record review, the facility failed to the facility must develop and implement a baseline care plan for 2 of 4 residents reviewed for baseline care plans. (Resident #43 and Resident #33) The facility failed to develop person baseline care plans within 48 hours of admission for Resident #43 and Resident #33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible and received adequate supervision for 3 residents (#8, #36 and #37) of 10 residents reviewed for supervision. The facility failed to have adequate staff supervision in the 300 hall Tea/Bistro room and main dining room, to ensure the pureed and mechanically soft diet residents were not at risk of getting or receiving solid foods from the snack stands. This failure could potentially place residents at risk of eating food not doctor ordered and unsafe for them to eat and drink, which could cause them to choke or aspirate, resulting in a decreased quality of life and psycho-social well-being.