Broadview Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to honor resident choices for one (#2) of three residents reviewed for self-determination out of five sample residents. Specifically, the facility failed to provide bathing for Resident #2 per her preference. Findings include: I. Facility policy and procedure The Promoting/Maintaining Resident Self-Determination policy, undated, was provided by the nursing home administrator (NHA) on 2/24/25 at 4:16 p.m. It read in pertinent part, It is the practice of this facility to protect and promote resident rights by facilitating resident self-determination through support of resident choice. The facility will ensure that each resident has the opportunity to exercise his/her autonomy regarding those things that are important in his/her life such as interests and preferences. All staff members involved in providing care to residents will promote and facilitate resident self-determination. It is the residents' right to determine what, if anything, they would prefer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#1) of three residents reviewed for quality of care out of eight sample residents. Specifically the facility failed to: -Assess and monitor Resident#1 after she developed eye drainage; and, -Ensure the facility's physician was aware Resident #1 had been diagnosed with clogged eye ducts and prescribed antibiotics for the condition by an outside provider. Findings include: I. Facility policy and procedure The Notification of Changes policy and procedure, dated 9/1/24, was provided by the nursing home administrator (NHA) on 12/18/24 at 4:30 p.m. It read in pertinent part, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. -The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazardous situations for two (#7 and #3) of five residents reviewed for accident hazards out of eight sample residents. Specifically, the facility failed to repair the handicap-accessible door to the smoking patio in a timely manner and ensure the door functioned properly and was safe to use while it was broken for Resident #7 and Resident #3. Findings include: I. Facility policy and procedure The Fall Management System policy, revised November 2024, was received from the nursing home administrator (NHA) on 12/18/24 at 4:07 p.m. It read in pertinent part, It is the policy of this facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. The quality assessment and assurance (QAA)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored in two of four medication carts and in one of one medication storage room. Specifically, the facility failed to ensure: -Medications were labeled with the date opened; and, -Expired and discontinued medications were removed from the medication carts in a timely manner. Findings include: I. Professional references According to the manufacturer Sanofi Aventis US, How to Use Your Lantus Solostar Pen (August 2022), retrieved on 2/20/24 from https://www.lantus.com/dam/jcr:817aed9c-a677-4cd6-a6b3-d93d8aba629a/lantus-solostar-pen-guide.pdf, After 28 days, throw your opened Lantus pen away, even if it still has insulin in it. According to the manufacturer NovoNordisk, Taking Novolog-Insulin Aspart (March 2023), retrieved on 2/20/24 from https://www.mynovoinsulin.com/insulin-products/novolog/taking-novolog.html, Storage after use - keep at room temperature or refrigerated up to 28 days.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed manage the pain of three (#15, #36 and #12) of five residents out of 22 sample residents in a manner consistent with professional standards of practice Specifically, the facility failed to ensure residents consistently received scheduled pain medications on time. Findings include: I. Professional reference According to the National Institutes of Health (NIH), National Library of Medicine, Nursing Rights of Medication Administration (September 2023), retrieved on 2/21/24 from https://www.ncbi.nlm.nih.gov/books/NBK560654/, It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration. Right time- administering medications at a time that was intended by the prescriber. Often, certain drugs have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure one (#47) of one resident out of 22 sample residents received the proper treatment and assistive devices to maintain hearing. .Specifically, the facility failed to: -Obtain an order for ear wax drops in order for the audiologist to perform a hearing test for Resident #47; and, -Obtain a follow-up appointment with the audiologist to address Resident #47's concerns with his hearing ability. Findings include: I. Facility policy and procedure The Ancillary Services policy and procedure, dated 11/4/13, was received by the nursing home administrator (NHA) on 2/14/24 at 4:40 p.m. It read in pertinent part: Purpose: Ancillary services, including, but not limited to, dental, vision, audiology and podiatry will be provided to the resident per state and federal regulatory guidelines at the resident/responsible family member's request and as needed. Policy: Any resident needing or requesting ancillary services such as dental, vision,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure one (#51) of one resident reviewed for abuse out of 22 sample residents was kept free from abuse. Specifically, the facility failed to keep Resident #51 free from sexual abuse by Resident #6. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 2/12/24-2/15/24, resulting in the deficiency being cited as past noncompliance with a correction date 11/3/23. I. Facility policy and procedure The Abuse Policy, dated 5/3/23, was received by the nursing home administrator (NHA) on 2/13/24 at 11:09 a.m. It read in pertinent parts: Purpose: Communities does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends, or any other individuals.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to maintain nurse unit refrigerators used for resident snacks and nourishment on three of three nurse units with proper temperatures to prevent foodborne illness, and without accurate temperature logs or cleaning. These failures had the potential to cause foodborne illness among residents who eat food prepared in the facility's kitchen and stored in the unit refrigerators. Findings include: I. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/Reg_BOH_RetailFoodRegulations.pdf, read in pertinent part, Ready-to-Eat, Potentially Hazardous Food (Time/Temperature Control for Safety Food) served in facilities providing food to highly susceptible populations shall adhere to the following date marking requirements: Refrigerated,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality for one resident (#27) out of five sample residents reviewed for dignity out of 36 sample residents. The facility failed to treat the resident with dignity and respect by not addressing Resident #27's concerns through the grievance process. The facility failed to act upon a report from Resident #27 that the nursing home administrator (NHA) hurt her feelings by asking her to leave his office if she was there to complain, therefore the facility did not initiate the grievance process in order to provide timely follow-up and resolution. Due to the NHA not taking the resident's grievance, the resident stated she cried after what the NHA said to her about her concerns, was tearful during an interview during the survey, and stated she was afraid of retaliation when expressing her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that one (#71) out of five sample residents reviewed for grievances out of 36 sample residents were provided prompt efforts by the facility to ensure all grievances were followed up on and resolved promptly and appropriately. Specifically, the facility failed to follow up on Resident #71's concerns promptly, which were brought forward to staff members. Findings include: I. Facility policy and procedure The Resident and Family Grievances policy, revised 10/1/22, was provided by the clinical nurse consultant (CNC) on 11/16/22 at 3:36 p.m. It read in pertinent part, Grievances may be voiced in the following forums: -Verbal complaint to a staff member or grievance official. -Written complaint to a staff member or grievance official written complaint to an outside party. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form, or assist the resident or family to complete the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for one (#27) of five residents reviewed for oxygen therapy out of 36 sample residents. Specifically, the facility failed to ensure oxygen was administered according to physician orders for Resident #27. Findings include: I. Facility policy The Oxygen Administration policy, revised on 10/1/22, was provided by the director of nursing (DON) on 11/16/22 at 3:20 p.m. It read in pertinent part, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Oxygen will be administered under orders of a physician. The policy explanation and compliance guidelines documented that the resident's care plan shall identify the interventions for oxygen therapy, based on the resident's assessment and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interviews, the facility failed to maintain an infection control and prevention program designed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections in one out of four units. Specifically, the facility failed to provide peri care and skin assessment to Resident #74 in a sanitary manner. Findings include: I. Peri care and skin assessment observations Licensed practical nurse (LPN) #3 was observed completing skin assessment and peri care for Resident #74 on 11/16/22 at 4:14 a.m. with assistance from certified nursing aide (CNA) #4. LPN #3 applied clean gloves, positioned the resident on his back and assessed his legs. She pulled off his socks to look at the heels, and put his socks back on. Without changing her gloves she removed the resident's brief and discarded it into the trash. She attempted to clean the resident's penis with peri wipes. The resident had a sensitive area at the tip of his penis with a mild bright red discharge. After the resident communicated to her his…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to prevent abuse for one (#51) of five out of 31 sample residents. Specifically, the facility failed to protect Resident #51 from abuse from Resident #25. Findings include: I. Facility policy The Abuse policy, with no revision date, was received from the nursing home administrator (NHA) on 8/4/21 at 12:10 p.m. It read in pertinent part: The policy statement was revised to indicate additional types of abuse that are prohibited, exploitation, corporal punishment, and physical or chemical restraints. Abuse includes the deprivation of an individual of goods or services necessary to maintain physical, mental and psychosocial well being. It includes verbal abuse, physical abuse, sexual abuse and mental abuse.Sexual abuse is now defined as nonconsensual sexual contact of any kind with a resident. II. Abuse investigation Suspected abuse investigation was initiated on 7/9/21 at 3:30 p.m. The report was received from the NHA on 8/5/21 at 12:24 p.m. It read in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interviews the facility failed to maintain an infection program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection such as coronavirus (COVID-19) for two (#49 and #53) of two residents out of 31 sample residents. Specifically, the facility failed to ensure the use of proper personal protective equipment (PPE) gloves when collecting a polymerase chain reaction (PCR) COVID-19 swab from Resident #49 and #53. Findings include: I. Professional reference According to Center for disease control (CDC) guidance, Collecting and Handling Specimens Safely, updated 2/26/2021, retrieved online 8/9/21 from: https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html, For healthcare providers collecting specimens or working within 6 feet of patients suspected to be infected with SARS-CoV-2, maintain proper infection control and use recommended personal protective equipment (PPE), which includes an N95 or higher-level respirator (or facemask if a respirator is not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.