Broadway Manor Care Center

In the surveyor’s words

From the most serious findings on record at Broadway Manor Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Apr 4, 2025

  Based on interviews and record reviews, the facility failed to ensure Licensed Vocational Nurse [LVN] 1 and Registered Nurse Supervisor (RNS) 1 consulted and notified the attending physician (Physician 1) and/or Physician Assistant (PA) 1 of a resident's significant change in condition (refers to a major decline in a resident's health status that requires a comprehensive reassessment that is not expected to resolve on its own or through standard medical interventions) for one of two sampled residents (Resident 1) in accordance with Resident 1's physician's order and care plan developed to monitor Resident 1 and notify the physician for adverse reaction (unwanted, unexpected, or harmful effect resulting from a medication or other treatment), while receiving Eliquis (a brand of anticoagulant… […]

• Actual harm, isolatedF684Mar 18, 2025

  Amended Copy - [DATE] Based on interview and record review the facility failed to assess, monitor for the signs and symptoms of Peripheral Arterial Disease (PAD- also known as peripheral vascular disease [PVD], a circulatory problem where narrowed arteries reduce blood flow to the legs, arms, or other parts of the body, often due to plaque buildup), and follow the general acute care hospital (GACH 1) physician and facility ' s attending physician ' s recommendations for one of three sampled residents (Resident 1), who was recently hospitalized for an acute cerebrovascular accident (CVA - a type of stroke [occurred when blood flow to the brain was interrupted], loss of blood flow to a part of the brain), right internal carotid artery stenosis ([NAME]- a condition that happens when the… […]

• No harm, potential for more than minimal, patternF656Feb 12, 2026

  Based on observation, interview, and record review, the facility failed to develop a comprehensive resident specific care plan for three of eight sampled residents (Resident 4, 8 and 31) in accordance with the facility's policy and procedures. A care plan for Resident 4 and 31 was not developed for management of dementia ( a progressive brain disorder that affects memory and thought process). This failure had the potential to result in the resident not to receive the necessary care needs and psychosocial needs, increased behavioral escalation, resident distress, and risk of harm. 2. A care plan for Resident 8 was not developed for the management of self inflicted wound of both hands by picking at his nails and skin using fingers on both hands. […]

• No harm, potential for more than minimal, patternF755Feb 12, 2026

  Based on observation, interview, and record review the facility failed to: 1.Reconcile (the process of comparing transactions and activity to supporting documentation) two medication emergency kitS ([eKIT] - kit containing medications needed to be used during emergencies) containing lorazepam (a controlled substance [CS - medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as narcotics or Controlled Medication [CM] used for anxiety) for February 2026, in one of two Medication Rooms (Medication Room Station A) inspected. 2. […]

• No harm, potential for more than minimal, patternF761Feb 12, 2026

  Based on observation, interview, and record review the facility failed to label, discard medications and stored safely, following manufacturer's recommendations and in accordance with the facility's Policy and Procedure (P&P) titled Medications and biologicals by failing to: 1.Label one (1) open Lantus (type of long-acting insulin [medication that lowers blood sugar]) in a Solostar pen (a type of prefilled syringe containing insulin) stored in Medication Cart 2 at room temperature for one of three sampled residents (Resident 83). 2. […]