A list of the most recent deficiencies for Broadway Villa Post Acute. 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 | 2023-10-23 | 2023-12-21 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-10-23 | 2023-12-21 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-10-23 | 2023-12-21 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-10-23 | 2023-12-21 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-10-23 | 2023-12-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-23 | 2023-12-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-23 | 2023-12-21 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2023-10-23 | 2023-12-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-23 | 2023-12-21 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-10-23 | 2023-12-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-23 | 2023-12-21 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-23 | 2023-12-21 | Y |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-10-23 | 2023-12-21 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2023-10-23 | 2023-12-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-23 | 2023-12-21 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-01 | 2023-11-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-11-01 | 2023-11-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-11-01 | 2023-11-16 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-11-01 | 2023-11-16 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2023-11-01 | 2023-11-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-01 | 2023-11-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-11-01 | 2023-11-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-01 | 2023-11-16 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-11-01 | 2023-11-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-11-01 | 2023-11-16 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-11-01 | 2023-11-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-01 | 2023-11-16 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-06-29 | 2022-08-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-29 | 2022-08-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-29 | 2022-08-12 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-06-29 | 2022-08-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-29 | 2022-08-12 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2022-06-29 | 2022-08-12 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-06-29 | 2022-08-12 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-06-29 | 2022-08-12 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-06-29 | 2022-08-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-29 | 2022-08-12 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-06-29 | 2022-08-12 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-06-29 | 2022-08-12 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-29 | 2022-08-12 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-06-29 | 2022-08-12 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-06-29 | 2022-08-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-29 | 2022-08-09 | Y |
| 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 | 2022-06-29 | 2022-07-27 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-07-05 | 2022-07-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-05 | 2022-07-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-05 | 2022-07-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-05 | 2022-07-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-07-05 | 2022-07-19 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-06-29 | 2022-07-18 | Y |
| Keep all essential equipment working safely. | Health | 2022-06-29 | 2022-06-30 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-11 | 2022-06-02 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-10-18 | 2021-12-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-18 | 2021-12-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-01 | 2021-09-22 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-03 | 2019-10-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-03 | 2019-10-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-03 | 2019-10-22 | 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 | 2019-08-15 | 2019-10-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-08-15 | 2019-10-01 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-08-15 | 2019-10-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-08-15 | 2019-10-01 | 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 | 2019-08-15 | 2019-10-01 | N |
| Dispose of garbage and refuse properly. | Health | 2019-08-15 | 2019-10-01 | N |
