Broadmead

In the surveyor’s words

From the most serious findings on record at Broadmead, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Nov 20, 2025

  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,… […]

• No harm, potential for more than minimal, patternF887Nov 20, 2025

  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… […]

• No harm, potential for more than minimal, isolatedF578Nov 20, 2025

  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… […]

• No harm, potential for more than minimal, isolatedF684Nov 20, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF695Nov 20, 2025

  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. […]