Broadview Health and Rehabilitation Center

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Egress Deficiencies

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Pharmacy Service Deficiencies

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.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Construction Deficiencies

Meet requirements for sections of health care facilities separated by fire resistive construction.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Miscellaneous Deficiencies

Have restrictions on the use of highly flammable decorations.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Based on document review, observation, and interview, it was determined that the Fire Sprinkler system was not maintained. The deficient practice could affect seven out of seven smoke compartments, 100 out of 100 residents, and an indeterminable number of staff and visitors. .. Based on observation and interview, the facility failed to maintain the fire rating of hazardous areas. The deficient practice affected 1 out of 7 smoke compartments, 14 out of 100 residents, and an indeterminable number of staff and visitors. .. Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain the means of egress. The deficient practice affected all seven smoke compartments and all facility residents, staff, and visitors. .. Based on observations and interviews during the survey, the facility failed to maintain one motion locking arrangements in the facility. The deficient practice could affect one out of seven smoke compartments, 14 out of 100 residents, and an indeterminable number of staff and visitors. .. Based on observations and interviews with the administrator and maintenance director, it was determined that the fire panel was not maintained. The deficient practice could affect all seven smoke compartments, all residents, and an indeterminable number of staff and visitors. .. Based on the record review and staff interview during the survey, the facility failed to maintain all corridors. The facility utilizes swamp coolers. The deficient practice could affect all seven smoke compartments, all residents, and an indeterminable number of staff and visitors. .. Based on the record review and staff interview during the survey, the facility failed to schedule fire drills under varied conditions. This deficient practice could affect all seven smoke compartments, all residents, and an indeterminate number of staff and visitors. .. Based on the records review and the interview, the facility failed to inspect and test all emergency lighting. The deficient practice affected all seven smoke compartments and all facility residents, staff, and visitors. The facility failed to furnish the annual 90-minute testing for the emergency exit lights throughout the facility. .. The Initial Comments (ID Tag 0000) are informational only and represent the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is a one-story, Type V (000), wood frame structure with a partial basement area used for building service..

A complaint survey, prompted by #CO39245 and Incident #38905 was conducted on 2/24/25. One deficiency was cited. Based on record review and interviews, the facility failed to honor resident choices for one (#2) of three residents reviewed for self-determination out of five sample residents.Specifically, the facility failed to provide bathing for Resident #2 per her preference.Findings include:I. Facility policy and procedureThe Promoting/Maintaining Resident Self-Determination policy, undated, was provided by the nursing home administrator (NHA) on 2/24/25 at 4:16 p.m. It read in pertinent part, "It is the practice of this facility to protect and promote resident rights by facilitating resident self-determination through support of resident choice. The facility will ensure that each resident has the opportunity to exercise his/her autonomy regarding those things that are important in his/her life such as interests and preferences."All staff members involved in providing care to residents will promote and facilitate resident self-determination."It is the residents' right to determine what, if anything, they would prefer to do or not to do each day in accordance with physician orders and resident' s abilities."Each resident has the right to choose their schedules (including sleeping, eating, bathing and waking times), consistent with their interests, assessments, and plans of care."Each resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident."The Resident Showers policy, undated, was provided by the NHA on 2/24/25 at 3:14 p.m. It read in pertinent part, "It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice."Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety."Partial baths may be given between regular shower schedules as per facility policy."The CNA (certified nurse aide) will assess the skin for any changes while performing bathing and inform the nurse of any changes."II. Resident #2A. Resident statusResident #2, age less ..

A complaint survey, prompted by #CO36652, #CO37225 and #CO38261 was conducted on 12/18/24. Two deficiencies were cited. Based on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazardous situations for two (#7 and #3) of five residents reviewed for accident hazards out of eight sample residents. Specifically, the facility failed to repair the handicap-accessible door to the smoking patio in a timely manner and ensure the door functioned properly and was safe to use while it was broken for Resident #7 and Resident #3.Findings include:I. Facility policy and procedureThe Fall Management System policy, revised November 2024, was received from the nursing home administrator (NHA) on 12/18/24 at 4:07 p.m. It read in pertinent part, "It is the policy of this facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs."The quality assessment and assurance (QAA) committee will analyze trends related to falls and will determine if further intervention is needed."II. Resident group interview and observationsA group interview was conducted on the facility' s smoking patio on 12/18/24 at 10:24 a.m. with four residents (#3, #4, #5 and #6) who were identified as interviewable by the facility and assessment. Resident #3 said the handicap button.. Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#1) of three residents reviewed for quality of care out of eight sample residents. Specifically the facility failed to:-Assess and monitor Resident#1 after she developed eye drainage; and, -Ensure the facility' s physician was aware Resident #1 had been diagnosed with clogged eye ducts and prescribed antibiotics for the condition by an outside provider.Findings include:I. Facility policy and procedureThe Notification of Changes policy and procedure, dated 9/1/24, was provided by the nursing home administrator (NHA) on 12/18/24 at 4:30 p.m. It read in pertinent part, "The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident' s physician and notifies, consistent with his or her authority, the resident' s representative when there is a change requiring notification." -The policy did not include any pertinent information regarding documentation and assessment that must be completed upon a change of resident' s condition. II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on 10/22/23. According to the December 2024 computerized physician orders (CPO), diagnoses included osteoarthritis, rheumatoid..