Broadway House for Continuing Care

Complaint # 2961489Based on interviews, medical record reviews, and review of pertinent facility documents on 3/26/26, it was determined that the facility failed to report to the New Jersey Department of Health an injury of unknown origin that was identified on 3/18/26, following the resident's transfer to the emergency room (ER), where they were diagnosed with left femur (leg) fracture. This deficient practice was identified for 1 of 4 residents reviewed (Resident #1).The evidence was as follows: According to the Resident Face Sheet, Resident #1 was admitted to the facility with diagnose that included but were not limited to Dementia, with behavioral disturbances, psychotic disorder with hallucinations, seizures, and chronic candidiasis of vulva and vagina. According to the quarterly Minimum Data Set (MDS), an assessment tool, dated 1/15/26, Resident #1 had a Brief Interview Mental Status score of 9 out of 15, indicated that the resident was moderately cognitively impaired. A review of Progress Notes dated 3/19/26 at 8:41 AM revealed that the facility was contacted by a Hospital…

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 observation, interview, and record review, the facility's failed to have an adequate water management program. The facility's water management program was incomplete and was not consistent with current ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Guideline, which specifically called for design and maintenance procedures for the potential exposure of Legionnaire's disease (a serious pneumonia infection) within a healthcare facility. This failure created the potential for the 65 facility residents, who were either over the age of 65 and/or were autoimmune compromised, to be infected by Legionella. Findings include: Review of website for ASHRAE titled Successfully Managing the Risk of Legionellosis dated 04/07/21 indicated . Legionellae the biological classification name for a [NAME] of bacteria.is the plural, referring to more than one Legionella bacterium.Legionellosis: any illness (disease) caused by the exposure to Legionella. Legionnaires' disease (LD) and Pontiac…

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 interview, record review, and facility policy review, r the facility failed to ensure residents were free of abuse for one of one resident reviewed for abuse (Resident (R) 3) out of 21 sampled residents. R3 was physically abused by R119. This failure placed the resident at risk for physical injury and psychosocial harm. Findings include: Review of a facility policy titled Abuse, dated 01/01/25 indicated .Physical Abuse.Any inappropriate physical contact with a resident, such as hitting, slapping, striking with an open or closed hand, pinching, biting, kicking, rough handling, pulling of hair, twisting of limbs, or punching. Review of a document provided by the facility titled Resident Face Sheet indicated R3 was admitted to the facility on [DATE]. Review of a document provided by the facility titled quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/19/24 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated the resident…

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 interview, record review, and policy review, the facility failed to ensure two of two residents discharged to the hospital (Resident (R) 51 and R57) out of a total sample of 21 residents were provided with a bed hold notice within 24 hours of emergent transfer to the hospital. This failure increased the potential that residents would not know to request a bed hold and may be unable to return to the facility. Findings include: Review of the facility's policy titled Bed-Holds and Returns dated 01/01/25 revealed the following Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy (3) Prior to a transfer, written information will be given to the residents and resident representatives that explains in detail: (a) the rights and limitations of the resident regarding bed-holds; (b) the reserve bed payment policy as indicated by the state plan (Medicaid Residents) (c) the facility per diem rate required to hold a bed…

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 observation, interview, and record review, it was determined that the facility failed to: a.) follow interventions in the resident's care plan for smoking, b.) thoroughly complete two out of last three facility required safe smoking evaluations for a resident and c.) accurately code the resident's annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care as a smoker. This deficient practice was identified for one of one resident's, (Resident #19) reviewed for smoking and was evidenced by the following: On 12/15/22 at 10:24 AM, the surveyor observed Resident #19 seated in a wheelchair in front of the nurse's station. The resident stated that he/she lived at the facility before the Pandemic and that he/she liked to go outside and smoke cigarettes. The resident further told the surveyor that the facility had designated smoking times in which the resident was required to follow. The resident explained that he/she had to follow the rules if he/she wanted to keep smoking 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility failed to timely transmit a resident's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care in accordance with federal guidelines. This deficient practice was identified for one of 18 residents, (Resident #22) reviewed for the timely transmission of MDS's and was evidenced by the following: On 12/20/22 at 11:36 AM, the surveyor interviewed the MDS/Coordinator (MDS/C) who stated that she completed Resident #22's quarterly MDS dated [DATE], but she forgot to submit it to the Center for Medicare & Medicaid Services (CMS). The MDS/C stated that the facility had 14 days to submit an assessment after it was completed The surveyor reviewed the medical record for Resident #22. A review of the resident's Face Sheet (An admission Summary) reflected that the resident had resided at the facility since 2019 and had diagnoses which included but were not limited to hypertension (high blood pressure), acquired absence of…

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, it was determined that the facility failed to remove an expired controlled medication (Oxycodone) from the active back up supply for one (1) of three (3) medication storage rooms that were inspected for proper medication storage. The deficient practice was evidenced by the following: On 12/20/22 at 11:48 AM, the surveyor observed a Registered Nurse/Unit Manager (RN/UM) and a Licensed Practical Nurse (LPN) perform an inventory count for the controlled medications stored in the electronic back up supply machine for the facility. During the inventory count the RN/UM stated that there were eight (8) Oxycodone Immediate Release (IR) tablets in inventory and that was an accurate count. The surveyor, with the RN/UM and LPN, observed an expiration date of 11/19/22 for two (2) of the eight (8) tablets. The RN/UM stated that the two (2) tablets were expired and would need to be removed and destroyed appropriately. The RN/UM further stated that she was responsible for any discrepancies in the electronic back up supply machine for 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 interview and review of facility documentation, it was determined that the facility failed to ensure that Certified Nursing Aides (CNA) received 12 hours of mandatory annual in-service training that included abuse training for 1 of 5 CNA files reviewed (CNA #1). The deficient practice was evidenced by the following: On 12/20/22 at 12:30 PM, the surveyor reviewed the in-service education hours for five randomly selected CNA files, which were provided by the facility. The Nursing Education Record and Transcripts provided showed the following: CNA #1 had a hire date of 11/20/19. According to the Nursing Education Record and Transcript provided by the facility, CNA #1 had completed 6.5 hours of training from 11/20/21 to 11/20/22 which did not include training on abuse and the additional 5.5 hours of the required 12. On 12/20/22 at 1:05 PM, the surveyor interviewed the Nurse Educator (NE) regarding the education provided. The NE stated that the education provided was everything that she could find for each person. On 12/20/22 at 1:13 PM, the surveyor interviewed the NE regarding…

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, it was determined that the facility failed to maintain professional standards of nursing practice following a physician's order for parameters. This deficient practice was observed during medication administration for 1 of 1 resident, Resident #56, and was evidenced by the following: On 2/17/21 at 9:30 AM, the surveyor observed Resident #56 in bed. The resident was quiet and lying comfortably in bed. A review of the resident's Face Sheet (A one-page summary of important information about a patient) indicated that Resident #56 has diagnoses that included but were not limited to Hypertension (High Blood Pressure), Hypotension (Low Blood Pressure), and Diabetes Mellitus. On 2/22/21 at 9:15 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepare medication for administration to Resident #56 on unit 1 East. The surveyor noted an order documented on the Electronic Medical Record (EMAR) for Resident #56, Lisinopril 2.5 mg daily for Hypertension, Hold for Systolic Blood Pressure (SBP) less than 110. The LPN informed 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 the documentation, interview, and record review, it was determined that the facility Consultant Pharmacist (CP) failed to identify the contraindication of an opioid-dependent resident's use of as-needed opioid pain medication. This deficient practice was identified for 1 of 16 residents sampled and reviewed for CP evaluation, Resident #62, and was evidenced by the following: On 2/17/19 at 9:40 AM, the surveyor observed Resident #62 in bed in the resident's room, watching television. A review of Resident #62's Face Sheet (A one-page summary of important information about a patient established upon admission) revealed that the resident had diagnoses that included but were not limited to Opioid dependence, Generalized anxiety disorder, and Chronic Pain Syndrome. A review of the current Physician's Orders for Resident #62 documents an order for Dolophine 10 mg (Methadone) 6 tablets (60 mg) by oral route for Opioid dependency ordered soon after admission on [DATE], and Percocet 10 mg-325 mg 1 tablet every 6…

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, record, and policy review, it was determined that the facility failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and the potential for the development of foodborne illness. This deficient practice was evidenced by the following: On 2/24/21 at 10:12 AM, the surveyor, in the Dietary Director's (DD) presence, observed a bristle hairbrush fall to the floor from the top of the condiment station (metal shelf storing salt, pepper, ketchup, mustard, mayonnaise, and other condiments). The dietary aide, who was mopping the floor, then picked up the hairbrush from the floor and placed it back on top of the condiment shelf. The surveyor observed that along with the bristle hairbrush (having evident hair strands in between the bristles) was a head bandana and cellphone placed on the condiment shelf. The DD instructed the dietary aide to remove all his personal belongings from the condiment shelf and put it in the office for storage. On 2/24/21 at 10:30 AM, the surveyor interviewed the DD…

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 interview, it was determined that the facility failed to properly dispose and maintain waste in the garbage compactor area as evidenced by the following: On 2/24/21 at 10:10 AM, in the presence of the Dietary Director (DD), the surveyor observed the garbage compactor area to be littered with old cardboard boxes, old milk cartons, soiled plastic gloves, and soiled incontinence pad. The DD stated to the surveyor that the maintenance department of the facility was responsible for the cleaning of their garbage area. On 2/24/21 at 10:43 AM, the surveyor interviewed the Maintenance Director (MD) of the facility in the presence of another surveyor. The MD stated that the landlord of the facility's building was the one responsible for maintaining the garbage area clean. The surveyor requested a copy of a written agreement between the facility and the landlord that would indicate that the landlord of the building will be the one responsible for maintaining the garbage area clean. The surveyor also requested a copy of the facility's policy related to cleaning of 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.