A list of the most recent deficiencies for Broadway Manor Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-21 | 2024-01-18 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-12-21 | 2024-01-18 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-12-21 | 2024-01-18 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-12-21 | 2024-01-18 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-12-21 | 2024-01-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-21 | 2024-01-18 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-12-21 | 2024-01-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-21 | 2024-01-18 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-12-21 | 2024-01-18 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-12-21 | 2024-01-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-21 | 2024-01-18 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-12-21 | 2024-01-18 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-12-21 | 2024-01-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-21 | 2024-01-18 | N |
| Dispose of garbage and refuse properly. | Health | 2023-12-21 | 2024-01-18 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-12-21 | 2024-01-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-21 | 2024-01-18 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-12-21 | 2024-01-18 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-12-21 | 2024-01-18 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-12-21 | 2024-01-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-21 | 2024-01-18 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-12-27 | 2023-12-29 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-12-27 | 2023-12-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-27 | 2023-12-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-12-27 | 2023-12-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-12-27 | 2023-12-29 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-12-08 | 2023-01-09 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-12-21 | 2023-01-04 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-21 | 2023-01-04 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-03-18 | 2022-04-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-18 | 2022-04-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-18 | 2022-03-01 | Y |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-11-03 | 2021-12-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-11-03 | 2021-12-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-03 | 2021-12-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-11-03 | 2021-12-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-11-03 | 2021-12-01 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-10-29 | 2021-11-27 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-10-29 | 2021-11-27 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-10-29 | 2021-11-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-29 | 2021-11-27 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-10-29 | 2021-11-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-10-29 | 2021-11-27 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-10-29 | 2021-11-27 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-10-29 | 2021-11-27 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-10-29 | 2021-11-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-10-29 | 2021-11-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-10-29 | 2021-11-27 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-10-29 | 2021-11-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-29 | 2021-11-27 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-10-29 | 2021-11-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-29 | 2021-11-27 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-10-29 | 2021-11-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-07 | 2021-10-18 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-06-16 | 2021-08-03 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-05-06 | 2021-06-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-10 | 2021-04-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-03 | 2019-10-07 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-09-03 | 2019-10-07 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-09-03 | 2019-10-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-09-03 | 2019-10-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-03 | 2019-10-07 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-09-03 | 2019-10-07 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-09-03 | 2019-10-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-03 | 2019-10-07 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-09-03 | 2019-10-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-09-03 | 2019-10-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-03 | 2019-10-07 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-09-03 | 2019-10-07 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-09-03 | 2019-10-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-03 | 2019-10-07 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-09-03 | 2019-10-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-03 | 2019-10-07 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-09-03 | 2019-10-07 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-09-03 | 2019-10-07 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-09-01 | 2019-09-27 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-09-01 | 2019-09-27 | N |
| Establish methods for sharing information. | Fire Safety | 2019-09-01 | 2019-09-27 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-09-01 | 2019-09-27 | N |
| Provide rooms that can be unlocked from inside without a key. | Fire Safety | 2019-09-01 | 2019-09-27 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-09-01 | 2019-09-27 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-09-01 | 2019-09-27 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-09-01 | 2019-09-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-01 | 2019-09-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-01 | 2019-09-27 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-09-01 | 2019-09-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-01 | 2019-09-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-01 | 2019-09-27 | N |
