Broadview Multi Care Center

Inspectors wroteBased on record review, review of a facility Self-Reported Incident (SRI), hospital record review and interview, the facility failed to provide adequate supervision to Resident #25, who required placement on the facility secured unit, frequent monitoring, and had a history of verbal, physical and/or combative aggressive behaviors, to prevent an avoidable resident injury. Actual Harm occurred on 08/22/25 at approximately 6:00 A.M when Resident #25 was found on the floor with two bruised and swollen eyes, reported pain rated a nine (out of ten with ten being the worst possible pain) and stated someone hit her. [...]

Inspectors wroteBased on record review, review of a facility self-reported incidents (SRIs), personnel file review, interviews and review of the facility policy, the facility failed to ensure residents were free from misappropriation. This affected six (Residents #26, #127, #156, #165, #167, and #168) out of seven residents reviewed for misappropriation. The facility census was 160.

Inspectors wroteBased on record reviews, review of a facility self-reported incident (SRI), interviews and review of the facility policy, the facility failed to ensure alleged incidents of misappropriation were thoroughly investigated. This affected five (Residents #26, #156, #165, #167, and #168) out of seven residents reviewed for misappropriation. The facility census was 160.

Inspectors wroteBased on record review, review of a facility self-reported incident (SRI), interview and review of facility policy, the facility failed to ensure an allegation of misappropriation was timely reported to the state agency. This affected one (Resident #127) out of seven residents reviewed for misappropriation. The facility census was 160.

Inspectors wroteBased on record review, observation, interview, review of the incident accident log, review of manufacture's guidelines, review of the Medication Omission report, review of the Notice of Corrective Action form, review of the Wrong Dose report, review of the National Library of Medicine and review of the facility policy, the facility failed to ensure residents were free of significant medication errors. This affected three (Residents #29, #34, and #169) out of 11 residents observed or reviewed for medication administration. The facility census was 160.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure Resident #29's room was maintained in a clean and sanitary manner. This affected one (Resident #29) out of six residents reviewed for physical environment. The facility census was 160.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, hospital documentation review, resident and staff interviews, review of the facility investigation, policy review and review of the facility initiated corrective action, the facility failed to ensure appropriate care and assistance was provided to prevent a resident fall during a mechanical (Hoyer) lift transfer. Actual Harm occurred on 06/05/25 when Resident #116 was transferred with a Hoyer lift using only one staff member and the incorrect Hoyer sling resulting in a fall approximately four feet to the floor causing extensive bruising, pain and abrasions. Resident #116 was transferred to the emergency room where he had multiple x-rays. This affected one resident (#116) of three residents reviewed for falls. [...]

Inspectors wroteBased on record review, observations, staff and resident interviews, the facility failed to ensure incontinent care needs were met in a timely manner for Resident #6. This affected one (Resident #6) of three residents reviewed for incontinence care. The facility census was 154.

Inspectors wroteBased on record review, observation and interview, the facility failed to provide the appropriate assistive device to enable residents to eat or drink independently. This affected two (Residents #19 and #25) of three residents reviewed for assistive devices and 19 residents reviewed for needing assistance with meals. This had the potential to affect three additional (Residents #64, #104, and #122) identified by the facility as also requiring adaptive equipment for eating and drinking. The facility census was 152.

Inspectors wroteBased on observation, interview, and review of the facility policy, the facility failed to ensure accurate portions were served according to the menu diet spread sheet. This affected 42 residents (#8, #24, #28, #33, #35, #37, #39, #41, #42, #44, #45, #55, #60, #81, #82, #83, #87, #92, #93, #95, #105, #112, #118, #120, #130, #132, #135, #143, #146, #149, #154, #155, #156, #157, #158, #160, #161, #162, #163, #164, #165, and #453). The facility census was 162. Findings Include: Observation of the lunch tray line meal service on 03/19/25 at 12:05 P.M. revealed a four ounce spoodle was used to serve the ham and beans and a three ounce spoodle was used to serve the fried potatoes. Review of the menu diet spread sheet revealed an eight ounce spoodle was supposed to be used for the ham and beans and a four ounce spoodle for the fried potatoes. Interview on 03/19/25 at 12:09 P.M. [...]

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect all residents except six residents (#26, #99, #104, #140, #158, and #305) who received nothing by mouth. Total census was 162. Findings Include: Observation during kitchen tour with Dietary Director #366 on 03/17/25 at 9:05 A.M. revealed a large broken beverage bottle and large container of strawberries with gray fuzzy growth located in the bottom of the extra refrigerator near the outside exit hallway to the kitchen. A large bag of salt and one cardboard box filled with graham cracker snacks were open to air and unlabeled located on the kitchen snack shelf. Additionally, two employee outside jackets were found together on the same kitchen snack shelf with food items. [...]

Inspectors wroteBased on observations and interview the facility failed to maintain clean and sanitary resident rooms and failed to ensure the outdoor courtyard used for smoking was not littered with cigarette butts. This affected 10 of 162 residents (Residents #9, #38, #49, #52, #53, #61, #111, #112, #164, #306). Facility census was 162.

Inspectors wroteBased on record review, observation and interview, the facility failed to provide a dignified dining experience for residents who required assistance with feeding. This affected one (Resident #21) of five residents observed for dining. Findings Include: Review of medical record for Resident #21 noted an admission date of 02/08/19. Diagnoses included multiple sclerosis, contracture to right and left elbow, right and left knee, and contracture of muscle, unspecified thigh. Review of the comprehensive Minimum Data Set assessment, dated 01/06/25, revealed Resident #21 had intact cognition and was dependent for eating. Review of the plan of care dated 02/11/19 noted Resident #21 had performance deficit related to multiple sclerosis and required assistance with feeding. Interventions included to provide extensive assistance with eating. Observations on 03/17/25 at 8:51 A.M. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure resident concerns of missing items were addressed timely. This affected two of two residents reviewed for missing items (Resident #61 and #131). The facility census was 162. Findings Include: 1. Interview on 03/17/25 at 12:15 P.M. with Resident #61 revealed his licenses, social security card and birth certificate that he kept in a locked drawer were missing; he did not suspect theft. He reported the missing items to staff but nothing happened. Interview on 03/19/25 at 11:40 A.M. with Social Worker #411 revealed she was told by Resident #61 several months ago that he was missing his driver's license, social security card and birth certificate that he kept in a locked drawer. Social Worker #411 stated she filled out a concern form and told Resident #61 she would help him to get the items replaced and he declined. [...]

Inspectors wroteBased on observation, record review, staff interviews, and facility policy, the facility failed to ensure Resident #112 was placed on contact isolation precautions per the physician orders. This affected one resident (#112) out of four residents reviewed for isolation precautions and had the potential to affect all residents in facility. Total census was 162. Findings Include: Review of the medical record for Resident #112 revealed an admission date of 10/02/24 with diagnoses including paraplegia, protein calorie malnutrition, multiple pressure ulcers stage four, ureterostomy, neuromuscular dysfunction of bladder, and anxiety disorder. Observation on 03/18/25 at 4:30 P.M. revealed door signage of enhanced barrier precautions (EBP) in place for Resident #112. Review of medical record revealed an order for isolation was entered on 12/12/24 for contact precautions. [...]

Inspectors wroteBased on record review, observations, and interviews, the facility did not ensure food was served at palatable temperatures. This had the potential to affect 151 residents that received meals from the facility. Three residents (Resident #12, #48, and #116) out of 154 residents received nothing by mouth. The facility census was 154.

Inspectors wroteBased on record review, review of a facility self- reported incident (SRI), review of facility investigation, review of facility policy, and staff interview, the facility failed to prevent the misappropriation of Resident #130's prescribed narcotics. This affected one resident (#130) of three residents reviewed for misappropriation. The facility census was 153.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents with their preferences during meals. This affected two residents (#13 and #66) out of three residents (#13, #66, and #91) reviewed for diets and weight loss. The facility census was 154.

Inspectors wroteBased on observation and interview the facility failed to provide a clean and sanitary environment. This affected five (#89, #110, #115, #134 and #180) residents and had the potential to affect all residents residing in the facility. The facility census was 178.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure adequate and timely incontinence care. This affected two (#53 and #89) of four residents observed for incontinence care. The facility also failed to ensure adequate urinary catheter care. This affected two (#9 and #65) of two residents observed for urinary catheter care. The facility census was 178.

Inspectors wroteBased on interview, medical record review, and review of facility policy, the facility failed to ensure a restorative program was established for contracture management as recommended by therapy. This affected one (#110) of three residents reviewed for contracture management. The facility census was 178.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure proper infection control techniques were used for residents on isolation precautions. This affected one (#146) of three residents observed for isolation precautions. The facility census was 178.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient staffing to timely transfer residents who required two person Hoyer lift assistance. This affected Resident #22 and had the potential to affect all eleven residents (Resident's #5, #22, #45, #69, #71, #76, #78, #87, #103, #143, #167) residing on the nursing unit who required a mechanical lift for transfers.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure sufficient staffing to meet the behavioral health needs of the residents. This affected Resident's #76 and #101 and had the potential to affect all 31 residents residing on their nursing unit. The census was 175.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #22 was assisted into bed timely after returning from an appointment. This affected one resident (Resident #22) and had the potential to affect eleven residents (Resident's #5, #22, #45, #69, #71, #76, #78, #87, #103, #143, #167 residing on the nursing unit who required a mechanical lift for transfers. The facility census was 175.

Inspectors wroteBased on interview, record review and review of facility policy the facility failed to ensure Resident #176's physician orders were followed for treatments to her left above the knee amputation stump. This affected one resident (Resident #176) out of three residents reviewed for treatments. The facility census was 175.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to ensure Resident #47's urine culture result report was reported timely to the physician, and failed to ensure Resident #10 and Resident #47 received appropriate incontinence care timely. This affected two residents (Resident #10 and #47) out of three reviewed for incontinence. The facility census was 175.

Inspectors wroteBased on observation, interview, record review, review of the facility policy and review of hospital records the facility failed to ensure Resident #142 received incontinence care timely, failed to ensure Resident #9 received services to care for his suprapubic catheter, and failed to ensure Resident's #76 and #93 received appropriate incontinence care. This affected three residents (Resident's #76, #93, #142) out of five residents reviewed for incontinence care and one resident (Resident #9) out of three residents reviewed for catheter care. The facility census was 170.

Inspectors wroteBased on observation, record review, review of email, review of facility policy the facility failed to ensure Resident's #104, #124 and #149 were provided milk that is palatable. This is affected three residents (Resident's #104, #124 and #149) and had the potential to affect all 166 residents who dined in the facility. The facility census was 170.

Inspectors wroteBased on interview, record review and review of the facility policy the facility failed to ensure Resident #93's resident representative was notified of a change of condition. This affected one resident (Resident #93) out of three residents reviewed for resident representative notification. The facility census was 170.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure Resident's #104 and #124 had a clean, sanitary and homelike environment. This affected two residents (Resident's #104 and #124) out of three reviewed for clean, sanitary environment. The facility census was 170.

Inspectors wroteBased on interview, record review, review of hospital records and review of the facility policy the facility failed to ensure Resident #93's central venous catheter dressing was changed and failed to ensure physician orders were obtained for the care of Resident #93's central venous catheter. This affected one resident (Resident #93) out of three residents reviewed for dressing changes. The facility census was 170.

Inspectors wroteBased on interview, record review and review of the facility policy the facility failed to thoroughly assess Resident #93's condition prior to dialysis treatment and failed to ensure Resident #93 was transported to the hospital timely when her dialysis catheter was not functioning and she could not receive renal dialysis. This affected one (Resident #93) of three residents reviewed for dialysis. The facility census was 170.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to ensure physician's orders were followed for Resident #187. This affected one resident (#187) of three residents reviewed for admission and discharge procedures. The facility census was 187.

Inspectors wroteBased on observation and interview the facility failed to provide a clean and sanitary environment. This had the potential to affect all residents residing in the facility. The facility census was 171.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medications were administered with an error rate of less than five percent. A total of four errors out of 25 opportunities for error were observed resulting in a 16 percent medication error rate. This affected one resident (#117) of two (#104 and #117) observed for medication administration. The facility census was 171.

Inspectors wroteBased on observation and interview the facility failed to ensure medications were not left unattended at the residents bedside. This affected one resident (#149) of three (#104, #117 and #149) observed for unattended medications. The facility census was 171.

Inspectors wroteBased on observation, record review and interview the facility failed to maintain Resident #146's wheelchair in good repair. This affected one resident (#146) of seven sampled residents requiring the use of a wheelchair.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure one resident (Resident #172) was provided adequate assistance with meals as recommended by therapy staff. This affected one (#172) of six residents reviewed for assistance with nutrition.

Inspectors wroteBased on record review and interview the facility failed to ensure Resident #93, who was dependent on staff for activities of daily living received timely and adequate showers per the resident's choice and the facility shower schedule. This affected one resident (93) of three residents reviewed for choices.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #62's oxygen tubing was maintained in a clean manner. This affected one resident (#62) of two residents reviewed with oxygen therapy.

Inspectors wroteBased on observation, record review and interview the facility failed to use appropriate hand washing and change gloves during medication administration for Resident #93 to prevent the spread of infection. This affected one resident (#93) of two residents sampled during medication administration.