Broadway Villa Post Acute

In the surveyor’s words

From the most serious findings on record at Broadway Villa Post Acute, in the surveyor’s own words.

• Immediate jeopardy, patternF725Jun 29, 2022

  Based on observation, interview and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills to provide nursing services to ensure resident safety and meet the healthcare needs of the residents, according to the acuity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] 1) the facility employed four Licensed Psychiatric Technicians (LPTs - LPTs B, H, L and M) to work in the role of Licensed Vocational Nurses (LVNs), of a total scheduled LVN workforce of 18, assigning the LPTs care of residents with complex clinical care needs, some with more than 35 different medical diagnoses. […]

• Actual harm, isolatedF684Jul 2, 2026

  Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received nursing care that was resident-centered and in accordance with nursing professional standards of practice when he experienced seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) in April 2026 (his second seizure) and in May 2026, both requiring transfer to the hospital and:1. His anti-seizure medication, Keppra, was completed (reached the 30-day stop date; date medication administration ends) on 5/18/26; Keppra was not reordered and nursing staff did not call his physician to ensure this was intentional, and not an error,2. […]

• Actual harm, isolatedF689Oct 18, 2021

  Based on interview and record review, the facility failed to recognize a resident's increased risk of falls and did not provide additional supervision to prevent a fall for 1 of 3 residents (Resident 1). This failure resulted in Resident 1 falling and requiring emergency transport to the hospital. Resident 1 was diagnosed with bleeding inside her skull and subsequently died . Findings: During a review of Resident 1's clinical record, the Face Sheet indicated the facility admitted Resident 1 on [DATE], with a diagnosis of [CONDITION(S)] (PD) (movement disorder that affects the nervous system), Multiple Fractures (a crack or break in bone) of Ribs, History of Falling, and [CONDITION(S)] (visual acuity -- vision that allows a person to see straight ahead of them) of ,d+[DATE] or less, in his… […]

• No harm, potential for more than minimal, widespreadF921Apr 10, 2026

  Based on observation, interview and record review, the facility failed to provide a safe and sanitary environment, affecting all residents who receive food from the kitchen, when there were gouged, cracked and broken tiles on the floors of the kitchen and dry goods storage room (storing shelf-stable food and ingredients like flour, grains, canned goods, and spices).These failures prevented thorough cleaning of the floor, creating an environment for bacteria (tiny, single-celled living organisms often called germs), mold and pests to thrive and can result in risks for food contamination and spread of foodborne illness (any illness resulting from eating contaminated/spoiled foods). Findings:During a concurrent observation and interview on 04/7/2026 at 9:36 a.m. […]

• No harm, potential for more than minimal, widespreadF812Oct 23, 2023

  Based on observation, interview, and record review, the facility failed to ensure safe food handling and sanitary practices, when: 1. Dietary Aide (DA) 2 failed to perform hand hygiene after touching a dirty utility cart, before touching a clean utility cart and clean dishes. 2. The Maintenance Supervisor (MS) failed to ensure one of one facility ice-machines was sanitized in accordance with the ice-machine's manufacturer's guidelines. These failures had the potential to result in cross contamination and foodborne illness in a highly susceptible resident population of 111 residents who were on oral diets. Findings: 1. […]