Broadway Villa Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received nursing care that was resident-centered and in accordance with nursing professional standards of practice when he experienced seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) in April 2026 (his second seizure) and in May 2026, both requiring transfer to the hospital and:1. His anti-seizure medication, Keppra, was completed (reached the 30-day stop date; date medication administration ends) on 5/18/26; Keppra was not reordered and nursing staff did not call his physician to ensure this was intentional, and not an error,2. Nursing staff discontinued one of two Keppra orders (a duplicate), both ordered on 5/29/26; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received nursing care that was resident-centered and in accordance with professional nursing standards and his goals of care, as indicated in his Nursing Care Plan (a document that contains essential information about a patient's condition, diagnosis, goals, interventions, and outcomes) when:1. Nursing staff did not inform him when changes were made to his medication regimen, and;2. Nursing staff did not medicate him for pain per physician orders. These failures: 1. Caused Resident 1 to feel out of control and horrible, 2. Caused his pain to go untreated for over twelve hours, contributing to his pain severity being an eight on the pain scale (The Pain Scale is a pain assessment tool; pain is described as 1-10 out of a possible ten. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe and sanitary environment, affecting all residents who receive food from the kitchen, when there were gouged, cracked and broken tiles on the floors of the kitchen and dry goods storage room (storing shelf-stable food and ingredients like flour, grains, canned goods, and spices). These failures prevented thorough cleaning of the floor, creating an environment for bacteria (tiny, single-celled living organisms often called germs), mold and pests to thrive and can result in risks for food contamination and spread of foodborne illness (any illness resulting from eating contaminated/spoiled foods).

Inspectors wroteBased on observation, interviews, and record reviews, the facility's direct care and maintenance staff failed to provide a homelike environment for one resident (Resident 47) of 29 sampled residents, when the wall and its baseboard molding that her bed's headboard was pushed up against needed repair. This failure decreased the facility's potential to provide Resident 47 with a clean and homelike environment.

Inspectors wroteBased on observation, interview and record review, the facility's nursing staff failed to implement care plan interventions for three residents (Resident 1, Resident 2, Resident 3) out of three sampled residents when fall risk interventions were not executed following an actual fall. These failures decreased the facility's potential to effectively implement their fall prevention program, thereby placing Residents 1,2 and 3 at risk for recurrent falls and further injury.

Inspectors wroteBased on interview and record review, the facility's licensed nurses (LNs) failed to provide pain management to one resident (Resident 4) out of six residents when Resident 4 was experiencing severe pain from a displaced, comminuted fracture (a severe break where the bone is broken in three or more pieces that are significantly shifted from their normal alignment) of the shaft (the long cylindrical section) of the left humerus (long bone of the upper arm). This failure resulted in Resident4 enduring unnecessary suffering and experience prolonged physical distress.

Inspectors wroteBased on interview and record review, the facility failed to implement measures to prevent a fall for one (Resident 1) of ten sampled residents when nursing staff did not ensure Resident 1 wore non-slip socks during an assisted transfer from his bed to a shower chair. This failure resulted in Resident 1 sustaining a laceration to the left foot and a 5th digit fracture.

Inspectors wroteBased on interview and record review the facility failed to report an injury of unknown origin within the required timeframe for one of one resident. The facility was visited by the police for an allegation of abuse related to this injury, and the facility failed to follow up and report the incident to State agencies as required. This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safetyFindings: On 12/24/25 at 9:16 a.m., the Department received a report from Adult Protective Services (APS) with an allegation of abuse. EMS (Emergency Medical Services) reported to APS they transported a Resident to the hospital with, bruising and pain to his hand, consistent with a grabbing injury. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent abuse for one resident (Resident 1) when Resident 2 pushed and hit Resident 1. This failure resulted in Resident 1 sustaining two skin tears.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a safe environment for three of seventeen sampled residents when three residents (Resident 7, 8 and 9) were left unsupervised while smoking cigarettes. This failure had the potential to cause resident burn injuries and a facility fire hazard.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure immediate resident assistance when call light system was inoperable or inaccessible for six (6) residents (Residents 1, 2, 3, 4, 5, and 6) of 17 residents. This failure had the potential for delayed resident care and emergency response times.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) for 2 (Resident #64 and Resident #79) of 26 sampled residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to hold insulin as ordered by the physician when the resident's blood sugar was out of parameters for 1 (Resident #57) of 5 sampled residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure medications were stored properly for 1 (Resident #37) of 6 sampled residents reviewed for accidents.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to have a physician order for the use of a continuous positive air pressure (CPAP) and failed to properly clean and store CPAP and nebulizer equipment for 1 (Resident #57) of 3 sampled residents reviewed for respiratory care.

Inspectors wroteBased on interview, document review, and facility policy review, the facility failed to ensure the daily staffing posted included the facility name and the actual hours worked by the licensed and unlicensed staff for 32 of 32 days reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 3) was treated with dignity and respect when a Certified Nursing Assistant (CNA) made an inappropriate comment to Resident 3. This failure resulted in Resident 3 feeling uncomfortable and insulted.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of abuse were reported within the required timeframe for three of four sampled residents (Resident 1, Resident 2 and Resident 3) when initial reports of an allegation of abuse were not received by the Department. These failures of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food handling and sanitary practices, when: 1. Dietary Aide (DA) 2 failed to perform hand hygiene after touching a dirty utility cart, before touching a clean utility cart and clean dishes. 2. The Maintenance Supervisor (MS) failed to ensure one of one facility ice-machines was sanitized in accordance with the ice-machine's manufacturer's guidelines. These failures had the potential to result in cross contamination and foodborne illness in a highly susceptible resident population of 111 residents who were on oral diets.

Inspectors wroteBased on interview and record review, the facility did not ensure its Social Service Manager (SSM) was qualified for her position, when the SSM was leading the Social Services Department since approximately June, 2023 (approximately four months), but did not hold a Bachelors Degree (four-year college degree covering standard general education requirements and a specialized area of interest) in a human services field ([NAME] including, but not limited to, sociology, special education, rehabilitation counseling, and psychology); the SSM had an Associates Degree (two to three-year college degree; academic qualifications below a bachelor's degree) in business. In addition, the SSM did not have prior Social Service work experience in a Skilled Nursing Facility (like the facility) prior to her employment, which began in April, 2023 (approximately six months earlier). [...]

Inspectors wroteBased on interview and record review, the facility's Quality Assurance and Performance Improvement Committee (QAPI, a data driven and proactive approach to quality improvement; process used to ensure services are meeting quality standards and assuring care reaches a certain level) failed to identify quality deficiencies and subsequently investigate and act upon the deficiencies once identified, as evidenced by: 1. Facility leadership did not identify that the Social Service's Manager (SSM) was not qualified to run the Social Services Department (Cross reference F850); 2. Clinical staff failed to recognize, evaluate, and address unplanned weight gain, and slow and progressive weight loss (Cross reference F692); and, 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents were treated with dignity and respect when: 1) Resident call lights (dome light typically located outside a resident's room providing a visual/audio indication of calls for help originating from the bedside and bathroom) were not answered and were not answered timely; and, 2) Staff communicated with each other, in front of residents, using languages residents did not understand. These failures caused the following: Confidential Resident (CR) 2 felt awful, CR 3 felt they would get [NAME] from staff, CR 5 felt lousy, CR 7 felt angry, CR 11 felt mad, CR 9 felt insulted, CR 8 felt disrespected, and CR 4 felt very frustrated and felt like she was not a whole person. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the MDS was accurately completed for three of 26 sampled residents (Residents 76, 56, and 38). This failure could potentially result in care planning for residents based on inaccurate information.

Inspectors wroteBased on interviews and records review, the facility failed to develop and implement person-centered care plans for 3 of 4 sampled residents (Resident 44, Resident 21, and Resident 110). These failures had the potential for facility staff to provide inadequate care to vulnerable residents when their individual needs and interests were not addressed appropriately.

Inspectors wroteBased on observation, interview, and record review, the facility licensed staff failed to meet professional standards of nursing practice when: 1. Nurses did not call to clarify the insulin order for one of two residents sampled for tube feeding (Resident 76); 2. Nurses did not call to clarify the decision-making capacity order for one of 10 residents sampled for accidents (Resident 269). These failures resulted in a lack of communication between disciplines and care givers that could potentially cause negative outcomes for vulnerable residents including: 1. uncontrolled blood sugars, or confusion about when to administer the insulin; 2. making decisions and signing consents for medical care without the mental capacity to understand the risks and benefits or the potential outcome of their decision.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an effective comprehensive system for monitoring parameters of nutritional status for three of ten sampled residents (Resident 38, Resident 19 and Resident 76), when: 1. a. Resident 38's Desirable Body Weight Range (DBWR - general term for a person's optimal weight for a particular height) was not consistently established with the involvement of Resident 38 and/or Resident 38's RP (Responsible Party), to reflect Resident 38's and/or the RP's personal goals and preferences and was not coordinated with the IDT (Interdisciplinary Team) to include the physician responsible for Resident 38's care. b. [...]

Inspectors wroteBased on interviews, and records review, the facility failed to maintain an effective infection control program, when nursing staff did not assess and monitor for signs of COVID-19 (Corona Virus Disease of 2019 - an infectious respiratory disease) for three of four sampled residents (Resident 44, 21 and 110), when Resident 44 tested positive for COVID-19 and Residents 21 and 110 were exposed to a COVID positive resident. This failure had the potential risk for exposing health care workers to undetected COVID-19 positive residents thereby exposing other residents, staff, and visitors of the infectious disease.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one residents (Resident 28), was able to have her provider care, from outside of the facility, incorporated into Resident 28's overall plan of care. This resulted in Resident 28's provider's recommendations being left out of the medical record and plan of care; due to lack of follow up after Resident 28 attended the appointment.

Inspectors wroteBased on observation and interview, the facility failed to ensure one (Resident 31) of two sampled residents had belonging's which did not have a resident identification. This failure resulted in a resident's article of clothing not being labeled appropriately and being placed in another resident's closet.

Inspectors wroteBased upon observation, interview and record review, the facility failed to put systems in place to safeguard one of one (Resident 30) sampled resident from misappropriation of resident funds. This failure had the potential of Resident 30's funds being used by someone else inappropriately, since Resident 30 was not able to safeguard his personal funds.

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change MDS (Minimum Data Set, an assessment tool) within 14 days of a change in condition for one of four residents, sampled for change of condition (Resident 76), when Resident 76 was hospitalized and came back to the facility with a G-tube (gastrostomy tube, a flexible tube surgically inserted through the abdominal wall to bring nutrition directly into the stomach). This failure could potentially lead to a lack information for staff to update Resident 76's care plan.

Inspectors wroteBased on observation, interview and record review, the facility did not provide trauma-informed care, for behaviors, for 1 of 5 residents sampled, when Resident 92 was experiencing claustrophobia, anxiety, and panic attacks. Resident 92 lived at the facility for approximately one year and informed staff he suffered from claustrophobia (extreme or irrational fear of small, enclosed, or confined places) but the facility did not assess or attempt to treat his mental health needs as evidenced by: 1. Staff did not develop nursing care plans (document that contains essential information about a patient's condition, diagnosis, goals, interventions, and outcomes) that addressed Resident 92's claustrophobia and accompanying anxiety; 2. Staff did not notify Resident 92's Physician about his reports of claustrophobia and anxiety; 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an order for a sippy cup for all beverages to ensure one of one sampled resident (Resident 18) could use the assistive device when drinking. Failure to provide appropriate assistive devices to residents who need them could impede their ability to drink independently and may result in decreased fluid intake.