The Springs Broadway

Inspectors wroteBased on interviews, record review, and facility policy review, it was determined that the facility failed to perform ADLs to maintain good nutrition, grooming, and personal care for one (Resident #2) of one resident reviewed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that activities of daily living (ADL) were performed, and nail care was completed for 2 (Resident #9 and Resident #49) residents of 8 sampled residents reviewed for ADLs.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that limited range of motion did not worsen for 2 residents (Resident #9 and Resident #49) of 3 sampled residents reviewed for range of motion.

Inspectors wroteBased on observation, facility record review and interview, the facility failed to ensure food was in the proper form for the residents, affecting six residents with orders for pureed diets in the facility.

Inspectors wroteBased on observations, facility record review and interview, the facility failed to ensure that cross contamination did not occur during lunch service for one out of one kitchen.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined that the facility failed to serve a palatable meal for 1 (Resident #1) of 3 residents reviewed for meal service.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain a safe, functional, sanitary, and homelike environment for the residents to promote dignity and prevent the potential injury for 15 (Rooms 210, 216, 222, 303, 304, 306, 309, 310, 313, 319, 320, 321, 322, 405, and 401) in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the janitor closet, the treatment nurse office, and the door to the dirty side of the laundry which contained chemicals were locked to prevent accidental ingestion by the residents. This failed practice had the potential to affect 18 mobile residents per a list provided by Administrator on 2/1/24.

Inspectors wroteBased on observations, record review, and interview, the facility failed to ensure a Bilevel Positive Airway Pressure (BiPAP) mask, a Continuous Positive Airway Pressure (CPAP) mask and oxygen tubing were properly stored in a closed bag or container when not in use to prevent potential cross contamination for 3 (Residents #27, #30, and #32) of 7 (Residents #7, #27, #30, #32, #46, #48 and #258) sampled residents who had a physician's order for BiPAP, CPAP and/or Oxygen use.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted profession principles, as evidenced by the Treatments Nurses office being unlocked and accessible to residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure meals were served at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 2 of 2 meals observed. The failed practice had the potential to affect 11 residents who received their meal trays in their room on the 200 (Front) Hall, 13 residents who received their meal trays on the 200 (Back) Hall, 13 residents who received their meal trays on the 300 (front) Hall, 13 residents who received their meal trays in their room on the 400 Hall, as documented on a list provided by the Dietary Supervisor on 01/30/2024 at 11:09 AM.

Inspectors wroteSurveyor: [NAME], [NAME] Based on observation and interview, the facility failed to ensure foods stored in the dry storage area refrigerator, and freezer were covered, sealed and dated to decrease the potential for food borne illness for residents who received meals from 1 of 1 kitchen; foods were dated the day received to assure first in, first out usage to prevent potential for food bone illness; kitchen wall and door frames, ceiling tiles ,and light fixtures were maintained in working and clean sanitary conditions for food preparation and were free of chipped paint to prevent the potential food borne illnesses for residents who received meals from 1 of 1 kitchen; expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the comprehensive care plan addressed the resident's medical and nursing needs related to oxygen use to promote continuity of care and meet the resident's needs for 1 (Resident #32) of 1 sampled resident who had physician orders for oxygen. This failed practice had the potential to affect 12 residents who had physician orders for oxygen therapy, according to a list provided by the Administrator on 02/02/24.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents hair was neat and clean, and facial hair shaven for 1 (Resident #160) of 31 (Residents #2, #4, #5, #7, #9, #12, #15, #16, #22, #30, #31, #32, #34, #39, #41, #43, #44, #46, #48, #50, #52, #55, #56, #159, #160, #208, #258, #259, and #359 sampled residents to maintain good hygiene and grooming.

Inspectors wroteBased on interview and record review, the facility failed to ensure notification of Medicare non-coverage were provided to inform the residents and/or their responsible parties of financial liability for continued care and services after their Medicare coverage was discontinued for 3 (Residents #12, #31 and #208) sampled residents who were discharged from Medicare Skilled services in the last 6 months and remained in the facility and/or discharged home.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure foods stored in the freezer, refrigerator and dry storage area were covered, sealed, and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired dairy products and food items were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria; dietary staff washed their hands between dirty and clean tasks and before they handled clean equipment or food items to prevent the potential for cross contamination. These failed practices had the potential to affect all residents who received meals from the kitchen (total census: 70) as documented on a list provided by Dietary Supervisor.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a splint, hand roll, or other positioning device was consistently utilized to prevent further decline in Range of Motion for 2 (Resident #7 and #42) of 5 (Resident #6, R #7, R #9, R #42, and R #47) sampled residents who had a contracture.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure meals were served at temperatures that were acceptable to the residents, to improve palatability and encourage good nutritional intake during 2 of 2 meals observed. The failed practice had the potential to affect 12 residents who received meal trays in their rooms on the 200 East Hall,18 residents who received meal trays in their rooms on the 200 Hall, 16 residents who received their meal trays in their rooms on the 400 Hall and 21 residents who received their meal trays in their rooms on the 300 Hall, as documented on a list provided by the Dietary Supervisor.

Inspectors wroteBased on observation, record review, and interview, the facility failed ensure an indwelling catheter was maintained in a way to ensure urinary flow was not obstructed, which had the potential to cause a UTI [Urinary Tract Infection], for 1 (Resident #29) of 3 (Resident #9, #24 and #29) sampled residents who had an indwelling catheter.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure a Percutaneous Endoscopic Gastrostomy (PEG) tube feeding bag was properly labeled to prevent possible contamination and infection for 1 (Resident #70) of 2 (Resident #9 and R #70) sample mix residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure oxygen was administered as ordered by the physician for 1 (Resident #70) of 4 (Resident #7, #9, #29, #70) sample mix residents who had a Physician's Order for oxygen.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a dairy product was served in accordance with the planned, written menu to meet the nutritional needs of the residents for 1 of 2 meals observed. These failed practices had the potential to affect 58 residents who received meal trays from 1 of 1 kitchen, according to a list provided by the Dietary Supervisor on 11/8/2022.