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Deficiency Records for Broadway Care and Rehab Center
A list of the most recent deficiencies for Broadway Care and Rehab Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Broadway Care and Rehab Center. 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 receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2024-07-10 | 2024-07-31 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-02-15 | 2024-03-15 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-02-15 | 2024-03-15 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-02-15 | 2024-03-15 | 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 | 2024-02-15 | 2024-03-15 | 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 | 2023-01-18 | 2023-03-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-01-18 | 2023-03-14 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-01-18 | 2023-03-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-18 | 2023-03-14 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-01-18 | 2023-03-14 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-01-18 | 2023-03-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-18 | 2023-03-14 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-01-18 | 2023-03-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-18 | 2023-03-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-01-18 | 2023-03-14 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-01-18 | 2023-03-14 | N |
| Respond appropriately to all alleged violations. | Health | 2023-01-18 | 2023-03-14 | 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 | 2023-01-18 | 2023-03-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-18 | 2023-03-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-18 | 2023-03-14 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-02-14 | 2023-03-14 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-02-14 | 2023-03-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-14 | 2023-03-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-02-14 | 2023-03-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-24 | 2022-03-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-24 | 2022-03-22 | Y |
| Report COVID19 data to residents and families. | Health | 2022-01-24 | 2022-03-22 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-17 | 2021-09-30 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2021-08-17 | 2021-09-30 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-08-17 | 2021-09-30 | 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 | 2021-08-17 | 2021-09-30 | N |
| Ensure that each resident is free from medications that restrain them, unless needed for medical treatment. | Health | 2021-08-17 | 2021-09-30 | N |
| Assess the resident when there is a significant change in condition | Health | 2021-08-17 | 2021-09-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-08-17 | 2021-09-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-17 | 2021-09-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-17 | 2021-09-30 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-08-17 | 2021-09-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-17 | 2021-09-30 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-08-17 | 2021-09-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-17 | 2021-09-30 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-08-17 | 2021-09-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-17 | 2021-09-30 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-08-17 | 2021-09-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-08-17 | 2021-09-30 | 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 | 2021-08-17 | 2021-09-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-17 | 2021-09-30 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-08-17 | 2021-09-30 | N |
| Keep all essential equipment working safely. | Health | 2021-08-17 | 2021-09-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-08-05 | 2021-09-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-08-05 | 2021-09-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-05 | 2021-09-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-17 | 2021-08-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-17 | 2021-08-17 | N |
| 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 | 2021-08-17 | 2021-08-17 | N |
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