Broadmead

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a tour of the kitchen, observation, and staff interview, it was determined that the facility staff failed to label stored food items to ensure safety and prevent contamination which could lead to unsafe food and potential illness.The findings include:During the initial tour of the kitchen on 11/17/2025 at 08:00 AM, the following items were found opened and used without any labeling:Walk in Refrigerator #1:1gallon [NAME] sauce w/ red raspberries1gallon sweet baby rays BBQ sauce x2 bottles1 gallon buffalo sauce x 2 bottles1 gallon each of salad dressings; Ranch, Golden Italian and French3 pound Hummus container1 32 oz horse radish containerWalk in Refrigerator #2:1 gallon Mayo1 gallon Harachino sauce 1 gallon pickle chips During an interview with staff # 8 on 11/17/2025 at 08:15 AM, he/she stated that all items that are opened and or used should have had a label with a use by date. Staff # 8 also stated that staff will need to be re-educated on labeling and dating of food items. On 11/19/2025 at 10:12 AM,…

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 record review and staff interviews, it was determined that the facility failed to maintain accurate records of staff COVID-19 vaccination status. This deficiency was evident for four (Staff #10, #11, #12, and #13) of the five staff reviewed for COVID-19 vaccinations. The findings include:On 11/19/25 at 11:33 AM, the surveyor reviewed the immunization records for five recently hired staff members who provide direct resident care. The staff reviewed included: Staff #10 and #11 (Hired May 2025), Staff #12 (Hired October 2025), and Staff #13 (Hired August 2025).The review revealed that four out of the five staff did not have records documenting their COVID-19 vaccination status.In an interview with the Infection Preventionist (Staff #5) and the Director of Nursing (DON) on 11/19/25 at 12:18 PM, they confirmed that the facility staff immunization records are managed by Human Resources (HR).During an interview with the HR Director (Staff #16) on 11/19/25 at 1:14 PM, she stated that the facility did not collect data regarding employees' COVID-19 vaccination status.At 1:34 PM on…

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 a review of the clinical record and staff interviews, it was determined that facility staff failed to properly document the primary decision maker for end-of-life decisions. This deficiency was evident in one (Resident #23) of the five residents reviewed for Advanced Directives during this annual survey.The findings include:The Medical Orders for Life-Sustaining Treatment (MOLST) form ensures that a patient's wishes to receive or decline care are honored. During the admissions process, a practitioner must review the MOLST form.Decision-making capacity is the ability of an individual to make an informed choice about a specific situation, such as medical treatment.On 11/17/25 at 1:12 PM, a review of Resident #23's medical record revealed that the resident's capacity certification was completed by two physicians on 7/21/25 and 7/22/25. Both physicians documented that the resident was not capable of making and communicating decisions regarding medical care.However, the MOLST dated 8/22/25 indicated that the orders were entered as a result of a discussion with and the informed…

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 a review of resident medical records and interviews with facility staff, it was determined that the facility failed to ensure residents received treatment and care to promote the highest practicable well-being evidenced by inadequate provision/monitoring of care when a resident experienced a voiding issue. This was evident for one (Resident #45) of 14 resident care records reviewed during this annual survey.The findings include:On 11/18/25, at 10:27 AM, the surveyor reviewed system-selected residents' closed records. The review revealed that Resident #45 was discharged from the facility on 9/18/25. A further review of Resident #45's progress notes revealed that the resident reported dark, tea-colored urine on 9/17/25, at 10:30 PM. An additional progress note, written on 9/19/25, at 2:07 AM, stated: Resident left AMA (against medical advice) overnight around 11:30 PM. Reports he/she was not urinating and concerned about the color of urine. [Spouse] was with him/her and took him/her via wheelchair by car…

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, record review, and staff interview, it was determined that the facility failed to 1) label oxygen tubing with date of change to indicate maintenance of the tubing for proper hygiene and safety, and 2) provide necessary respiratory care services for residents by failing to administer oxygen as prescribed. This was evident for three (Resident #23, #46, and #49) of 3 residents reviewed for respiratory care during this survey.The Findings include: 1) During the screening phase of the survey process on 11/17/25 at 10:30 AM, surveyor observed Resident # 46 and Resident # 49 receiving oxygen through nasal cannula tubing without a label indicating when they were changed. On 11/17/25, record review of resident # 46 noted an order for Oxygen at 2L – 4L/min via nasal cannula every shift for Cardiopulmonary Disorder (COPD). Resident # 49 had an order for Oxygen at 2L/min continuously every shift for Cardiopulmonary Disorder (COPD). On 11/18/25 at 09:30 AM, continued observation was made that the oxygen tubes were not labeled. During an interview with staff # 6, when asked…

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, medical record review, and interview with facility staff, it was determined that the facility failed to ensure that the environment of resident care was maintained in a manner that minimized the potential spread of infection, evidenced by an oxygen tube lying on the floor in a resident's room. This was evident for one (Resident #23) of two residents observed for oxygen therapy during this annual survey.The findings include:During the initial tour of the facility on 11/17/25 at approximately 10:00 AM, it was observed that Resident #23's oxygen tank was in the bathroom of his/her room, and the oxygen tube was lying on the floor from the tank to the resident's bed.The second observation, on 11/18/25 at 7:45 AM, noted that Resident #23's oxygen tube was still lying on the floor from the bathroom to the bed.In an interview with a Licensed Practical Nurse (LPN #2) on 11/18/25 at 7:45 AM, she stated that the facility's nurses manage residents' oxygen, including the tank, tube, and humidifier. The surveyor asked to observe Resident #23's oxygen tube. LPN #2 verified…

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 medical record review, and staff interview it was determined the facility failed to ensure residents received medications in accordance with professional standards of practice. This was evident for 1 resident (#10) out of 17 residents reviewed during the survey. The findings include the following: Review of Resident #10's medical record on 03/20/2024 at 09:30 AM revealed that the resident was discharged from the hospital and admitted to the facility on [DATE]. On the hospital discharge summary, it stated that Resident (#10) was to be given medication, Cefdinir, twice a day for 9 days as a course of antibiotic therapy and Resident (#10) was to begin Cefdinir on 02/21/2024. Review of facility investigation on 03/20/2024 at 11:00 AM revealed that Resident (#10) did not receive Cefdinir until 02/26/2024 and therefore missed 11 doses of this medication. During the interview with the Director of Nursing (#2) on 03/20/24 at 11:15 AM he/she confirmed the medication error and findings in the facility…

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 medical record review and staff interviews, it was determined that Pharmacy continued to prepackage a medication for Resident (# 29) after the medication was placed on hold. This occurred for 1 of 4 residents observed during the medication pass. The findings include: During observation of a medication pass on 3/20/24 at 9:00am with LPN (Licensed Practical Nurse) (Staff # 11) revealed that Resident #29 had Lasix 40mg in his/her prepackaged medications dated 3/20/24. Staff #11 stated, Lasix is in the package to be administered however, I know the medication is on hold. Review of the medical record on 3/20/24 at 11:30am revealed the medication was placed on hold on 3/15/24 at 9:30am. During an interview with the DON (Staff #2) on 3/20/24 at 1:30pm, she stated medications are delivered to the facility every 2 days for each resident and the Lasix should not have been in the package with Resident #29's medications. During a follow up interview on 3/20/24 at 2:15pm, the DON stated she spoke with pharmacy and the medication was being removed. All concerns were shared with 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.

Based on record reviews and interviews with facility staff, it was determined that the facility failed to address a pharmacy recommendation in a timely manner. This was evident for 1 (Resident #20) of 5 residents reviewed for unnecessary medications. The findings include: On 3/19/24 at 5:07 PM, record review of Resident #20's medical record revealed the following pharmacist recommendation dated 1/25/24, Please consider discontinuing PRN artificial tears and melatonin for no use in > 6 months. Furthermore, the document titled Letter to Physician, noting the response of the pharmacist's Recommendation and Medical Regimen Review (MRR) date of 1/25/24, contained a handwritten response of done. On 3/19/24 at 5:10 PM, record review of physician's orders in the electronic health record (EHR), revealed Resident #20 was ordered Artificial Tears Ophthalmic Ointment 83-15 % (White Petrolatum-Mineral Oil); Instill 1 application in both eyes every 24 hours as needed for Dry Eyes and Melatonin Oral Tablet 3 MG (Melatonin); Give 1 tablet by mouth every 24 hours as needed for Insomnia Give at…

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 staff interview, it was determined the facility failed to store food in accordance with professional standards for food safety. The findings include: An initial tour of the facility Kitchen was completed on 03/18/24 at 08:10 AM with Staff (#8) and the following items were found to be missing an expiration date on the product: 1) Two cans of black-eyed peas 2) Two boxes of classic salt 3) Several spice containers that included ground ginger 4) Two containers of avocado smash During the tour interview on 03/18/24 at 08:25 AM with Staff (#8), he/she stated that the above items did not have an expiration date on them and he/she would check on these items to be sure that they were able to be used and not expired.

Based on medical record review and interview, it was determined the facility staff failed to notify the responsible party for Resident (#34) of an increase in medication and obtain consent for that increase. This was evident for 1 of 5 residents selected for review of unnecessary medications during the survey process. The findings include: Medical record review for Resident #34 revealed the resident was seen by psychiatric nurse practitioner on 4/10/19. At that time, it was ordered: increase Lexapro to 15 milligrams by mouth at hour of sleep if OK with family. Lexapro is used to treat depression and anxiety. It works by helping to restore the balance of a certain natural substance (serotonin) in the brain. Further record review revealed the order for the Lexapro was written and initiated for Resident #34; however, the facility staff failed to notify the resident's family of the increase in the Lexapro and obtain consent for the medication increase. Interview with the social worker on 4/19/19 at 11:20 AM revealed the facility staff failed to notify the family of Resident #34 of an…

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 medical record review and interview, it was determined the facility staff failed to address and notify the physician of results of an abnormal blood sugar level for Resident (#24). This was evident for 1 of 27 residents selected for review during the annual survey process. The findings include: Resident #24 was admitted to the facility with diabetes which requires the body's blood sugar levels to be controlled by medications. A blood sugar level below 60 requires more sugar to be given to the resident and if above 300 requires extra medications to be given to lower the level. On 1/19/19 Resident #24's physician ordered the nursing staff to notify him/her if the blood sugar levels dropped below 60 or greater than 500. On 4/8/19 at 9 PM Resident #24's blood sugar level was documented on the medication administration as 534 and on 4/9/19 at 7 AM the level was 588. Interview with the Assistant Director of Nursing on 4/19/19 at 10:30 AM confirmed that on 4/8/19 at 9PM, and 4/9/19, the nursing staff did not document on the medication administration record, the treatment…

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.