The Broadmoor at Creekside Park

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure residents received adequate supervision for 1 of 7 residents (CR #1) reviewed for quality of care. CR #1 eloped from the facility on 02/23/2026 from an unwitnessed point of exit, and was located at the rear of the property at a school. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 02/23/2026 and ended on 02/23/2026. The facility corrected the non-compliance before the investigation on 03/10/2026. The IJ template was provided to the Administrator on 03/12/2026 at 2:02pm. This failure could place the residents with exit seeking behaviors at risk for injury or death.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to carry out activities of daily living necessary services to maintain grooming and personal hygiene reviewed for 2 of 7 residents (Resident #34 and Resident #123). The facility failed to ensure Resident #34 and Resident #123 received scheduled showers/bathing as required. This failure could result in skin breakdown, decreased self-esteem and quality of life.

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 permit only authorized personnel to have access to the keys for 1 of 5 residents (Resident #40 and Resident #68) and one of three medication carts (300 hall nurse cart) reviewed for storage of medications.1. The facility failed to keep Resident #40's medications secured. Eight unidentified medication tablets were found in a medication cup inside Resident #40's mini refrigerator. Resident #40 did not have orders to self-administer medications.2. The facility failed to keep Resident #68's medications secured. One albuterol solution was found in the resident's purse. Resident #68 did not have orders to self-administer medications.3. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents who require dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 1 resident (Resident # 124) reviewed for quality of care. The facility failed to ensure Resident #124's transportation arrangements were made for a dialysis (a medical procedure used to remove waste products and excess fluid from the blood when the kidneys are not functioning properly) appointment as physician ordered. Resident #124 missed a dialysis treatment on 3/10/26. This failure could affect residents who received transportation services for appointments, and place them at risk of complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs for 1 of 6 residents (Resident #100) reviewed for pharmacy services. The facility failed to account for one of Resident #100's Alprazolam 0.5 mg tablets from 3/11/26 - 3/13/26. This failure could place residents at risk for drug diversion and/or duplicate therapy.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 7%, based on 2 errors out of 27 opportunities, which involved 1 of 6 residents (Resident #48) and 1 of 5 staff (MA G) reviewed for medication administration. MA G administered two anti-hypertensives, Amlodipine and Lisinopril, (medications that reduce blood pressure) to Resident #48 without checking her blood pressure according to MD orders, the pharmacy label, and facility policy on 3/11/26. This failure could place residents at risk of low blood pressure and hospitalization.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly, for one out two dumpsters observed for garbage disposal. One facility dumpster lid was open and unsecured. This failure placed residents at risk of infection and a decreased quality of life due to having an exterior environment which could attract flying pests, rodents and other animals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, and comfortable environment for residents, staff, and the public for 2 (CR #1, Resident #1) of 5 residents and 2 (vacant room A, vacant room B) of 5 vacant rooms reviewed for sanitary conditions. 1. CR#1 was admitted on [DATE] into a room that had urine-stained sheets, brown fecal matter on the toilet seat and toilet bowl, and inside closet was wheelchair equipment left over from a previous resident. 2. Resident #1 had small black bugs crawling on the counter of the kitchenette inside her room on 12/12/25. 3. Vacant Room A had spider webs along the based boards, a urine stain on the fitted sheet, and dried fecal matter splatter inside of the toilet bowl on 12/12/25. 4. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 residents (CR #1) reviewed for quality of care.-The facility failed to ensure a thorough head to toe skin assessment was completed on CR #1 on 8/29/25. CR #1 was discharged to an acute care hospital on 8/30/25 and was diagnosed with a left groin abscess. This failure could place residents at risk of delayed treatment, pain and infection. Findings Include:Record review of CR #1's admission record dated 11/10/25 revealed a [AGE] year-old male who admitted on [DATE] and discharged on 8/30/25 to an acute care hospital. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 out of 6 residents (Resident #40) reviewed for ADL care. - The facility staff failed to provide scheduled showers/baths to Resident #40 on 12/7/24 and 12/14/24. - The facility failed to change Resident #40's shirt for 3 days (12/15/24, 12/16/24, and 12/17/24) when there was debris and stains on it. These failures could place residents at risk of a decline in ADL's.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete, accurately documented, readily accessible, and systematically organized for 3 of 6 residents (Resident #151, Resident #18, and Residetn #27) reviewed for medical records. - The facility failed to document Resident #151's treatments into his electronic record from 12/14/24 to 12/15/24. - The facility failed to have current care plans for Resident #18 and Resident #27 in the electronic health system. This failure could cause missed treatments and a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident who was incontinent of bowel/bladder and each resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections, for 2 of 6 residents (Resident #18 and Resident #87) reviewed for catheter care. - The facility failed to ensure physician orders for catheter care were entered into the system for Resident #18 and Resident #87 and staff were unable to document care provided from 12/1/24 to 12/17/24. This failure could place residents with foley catheters at risk for urinary tract infections and skin break down.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who needed colostomy care were provided such care, consistent with professional standards of practice for 1 of 6 residents (Resident #18) reviewed for ostomies (surgical opening from an area inside the body to the outside). - The facility failed to ensure physician orders for colostomy care were entered into the system for Resident #18 and staff were unable to document care provided from 12/1/24 to 12/17/24. This failure could place residents at risk of infection, skin break down, or discomfort.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 5 residents (Resident #59) reviewed for pharmaceutical services. - The facility failed to ensure Resident #59's order for Potassium Chloride was accurately transcribed when the order was entered as unsupervised self-administration. Staff documented the medication as unsupervised self-administration from 12/07/24-12/17/24 although Resident #59 did not self administer Potassium Chloride. This failure could place the resident at risk of not receiving their medication or receiving the medication more than once.

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 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 1 of 1 residents (Resident #18) reviewed for hospice services, in that: - The facility failed to ensure Resident #18's Hospice order was in the EMR from 12/1/24-12/17/24. This failure could place residents who receive hospice services at-risk of receiving inadequate end-of-life care, coordination of care and communication of resident needs.

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 1 of 6 residents (Resident #23) reviewed for Infection Control. Med Aide G failed to sanitize the blood pressure cuff between residents on 12/16/24. The blood pressure cuff was used on a Resident #250 who was on EBP and then placed on Resident #23 without being sanitized first. - This failure could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 3 residents (Resident #2, #3) reviewed for ADL care. The facility failed to provide timely incontinence care to Resident #2 and Resident #3. The noncompliance was identified as PNC. The noncompliance began on 4/6/24 and ended on 11/11/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for poor hygiene, diminished quality of life, and possible skin infections.

Inspectors wroteBased on interview, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility's assessment tool for 5 of 6 days (2/14/24, 2/15/24, 4/6/24, 4/7/24, and 4/9/24) reviewed for sufficient staff. The facility failed to have adequate staff to provide appropriate care to residents, resulting in multiple complaints of residents sitting in soiled briefs for 4-5 hours on 2/14/24, 2/15/24, 4/6/24, 4/7/24, and 4/9/24. The noncompliance was identified as PNC. The noncompliance began on 2/14/24 and ended on 11/18/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the right to be free from misappropriation of property was provided for 1 of 9 residents reviewed for misappropriation of property. (Resident #1) The facility failed to ensure Resident #1 was free from misappropriation of property when Housekeeper A gave Resident #1's purse to an unidentified individual. This failure could place residents at risk for decreased quality of life, misappropriation of property, and dignity.

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 one of three residents (Resident #4) reviewed for Infection Control. 1. The facility failed to ensure CNA D changed her gloves and performed hand hygiene while providing incontinent care to Resident #4 on 12/12/2024. This failure could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices based on the comprehensive assessment of resident (Resident #1) 1 of 6 residents reviewed for quality of care. -The facility failed to ensure staff remained with Resident #1 after Resident #1 was found on the floor, bleeding from his head. -The facility failed to complete an appropriate assessment for Resident #1 after an unwitnessed fall, where a laceration to the head and skin tear to the shoulder were sustained. These failures could place residents at risk of not receiving needed care and services to meet their physical, mental, and psychosocial needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pain management was provided to and monitored for 2 of 4 residents (Resident #128 and Resident #228), in that: -Resident #128 experienced pain after admission without her ordered Oxycodone available for use. -Resident #228 verbalized pain that without and pharmacological or non-pharmacological treatment offered to him. An Immediate Jeopardy (IJ) was identified on 09/27/2023 at 11:15AM. While the IJ was removed on 09/29/2023 at 06:37 PM, the facility remained out of compliance at a scope and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure caused Resident #128 and #228 to experience pain that went unmanaged and placed additional residents at risk for experiencing unmanaged pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services to meet the resident needs when the facility did not acquire the prescribed pain medications for 2 of 4 residents (Resident #128 and Resident #228) reviewed for medication administration, in that: -Resident #128 experienced pain after admission when her ordered Oxycodone was not available for use at the facility. -Resident #228 verbalized pain and was not offered pharmacological or non-pharmacological treatment to relieve his discomfort. An Immediate Jeopardy (IJ) was identified on 09/27/2023 at 11:15AM. While the IJ was removed on 09/29/2023 at 06:37 PM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan describing services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 18 residents, (Resident #132 and Resident #40), in that: - Resident #132 was not care for dementia diagnosis. - Resident #40 was not care planned for PEG tube and oxygen use. This failure placed residents at risk of not receiving adequate medical care in a timely manner.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 8 % based on 3 errors out of 35 opportunities, which involved 2 of 6 residents (Resident #9 and Resident #13) reviewed for medication errors. - RN C failed to observe Resident #13 self-administer her Fioricet with Codeine, a control substance used to treat headaches. - RN C failed to observe Resident #9 self-administer his Trelegy Ellipta inhaler, an inhaler used to treat COPD. - RN C failed to administer pre-meal HumaLOG insulin to Resident #9 due to the medication being unavailable. These failures could place residents at risk of not receiving the desired therapeutic effect of their medications and uncontrolled health conditions. Findings Include: [...]

Inspectors wroteBased upon observation interview and record review, drugs and biologicals used in the facility must be secured in locked compartments, labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 3 of 4 medication carts (500 Hall Nursing Cart, 200 Hall Nursing Cart, and 2-4 Med Aide Cart,) reviewed for drug labeling and storage. - The facility failed to ensure the 500 Hall Nursing Cart did not contain prescription medication with an illegible label. - RN C failed to ensure the 500 Hall Nursing Cart was locked when not in use and failed to ensure medication was not left at a Resident #9's bedside. - The facility failed to ensure Resident #133's Tramadol, a controlled substance pain medication, was behind a double lock in the 200 Hall Nursing Cart did not contain. [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately inform the resident's representative of a significant change in 1 of 4 residents (CR #133) physical and mental status. -The facility failed to ensure LVN G notified CR #133's representative of the resident's change in condition. This failure places residents at risk of not having the psychosocial and medical needs met as preferred.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a baseline care plan within 48 hours that included the minimum healthcare information necessary to properly care for the immediate needs of 1 of 18 residents, (Resident #131), in that: -The facility failed to ensure Resident #131's ADLs were included in her baseline care plan. This failure placed residents at risk of not receiving adequate care in a timely manner.

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 diseases and infections for 1 of 6 Residents (Resident #9) reviewed for infection control - RN C failed to ensure he used appropriate infection control practices while administering insulin to Resident #9. This failure could place residents at risk of skin infections.