Broadway by the Sea

In the surveyor’s words

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

• Immediate jeopardy, patternF758Jul 24, 2024

  Based on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 8) did not receive unnecessary psychotropic medication (medications that affect the mind, emotions, and behavior and used to treat mental health disorders). The facility failed to: 1. Ensure Resident 8 w, not prescribed and administered Ativan (a prescription medicine often used to treat people living with anxiety [extreme worry]) 1 milligrams ([mg] a unit of weight measurement), every four hours as needed (PRN) for agitation (feelings of irritability, mental distress, or severe restlessness) and shortness of breath (SOB) for 14 day, without documented indication for use. 2. […]

• Immediate jeopardy, patternF880Jan 11, 2022

  Based on observation, interview, and record review, the facility's staff failed to maintain and implement its infection control policies and procedures (P/P) and COVID-19 (a highly contagious [moving easily from one person to another] respiratory disease caused by [CONDITION(S)]-CoV-2 [a member of a large family of viruses called coronaviruses; these viruses can infect people and some animals]; spread mainly from person to person through respiratory droplets produced when an infected person coughs, sneezes, or talks) Mitigation Management Plan ([MMP] a set of actions to slow the spread of COVID-19) which indicated how to mitigate, manage, and prevent the spread of COVID-19 infection within the facility with the elements specified by the California Department of Public Health (CDPH) , which… […]

• Immediate jeopardy, isolatedF689Mar 20, 2024

  Based on observation, interview and record review, the facility failed to ensure the residents, who were assessed as a high risk for falls, had preventative measures implemented to prevent them from falls and injuries for three out of eight sampled residents (Residents 1, 3, and 4). The facility failed to: 1. Implement interventions including landing mats and bed alarm for Resident 1 as care planned Resident 1 had a history of falls on 10/24/2023 and 11/20/2024 and was assessed as a high fall risk. 2. Ensure Licensed Vocational Nurse (LVN 1) had knowledge of Resident 1's high risk for fall, how to access Resident 1' Care Plans, to implement interventions to safeguard Resident 1 from falls and injuries, and knowledge of facility's protocol for falls. 3. […]

• Actual harm, isolatedF656Feb 11, 2025

  Based on interview and record review, the facility failed to ensure the resident, who was assessed at risk for falls with poor safety awareness, did not fall and sustained injury for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1's untitled care plan, dated 7/5/2024, identifying the resident as fall risk, had specific interventions used and carried out to prevent the resident from falls and injuries. 2. Ensure untitled care plan, dated 7/5/2024, identifying Resident 1 as fall risk, was reviewed and revised after the resident's fall on 8/20/2024, to have specific interventions to safeguard the residents from future falls and injuries. 3. […]

• Actual harm, isolatedF686Nov 8, 2024

  Based on interview and record review, the facility failed to ensure a resident, who was assessed at a moderate risk for developing a skin injury and had intact skin upon admission, did not develop a Stage III (full thickness tissue loss - underlying fat tissue may be visible, but bone, tendon, or muscle is not exposed) pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) on the sacro-coccyx area (tailbone) measuring nine centimeters [(cm) unit of measurement] in length, nine cm in width and 0.1 cm in depth for one of two sampled residents (Resident 40). The facility failed to: 1. […]