Inspection Reports for
Broadview Health and Rehabilitation

The complaint investigation found that Resident #2 was not provided regular showers as preferred, with the resident reporting no showers from facility staff during February 2025 and feeling neglected. The resident preferred showers twice a week, but records showed fewer showers and documentation inconsistencies. The complaint was substantiated with findings of deficient care and documentation.

The facility failed to provide regular showers to Resident #2 as per her preference, resulting in minimal harm or potential for harm. Documentation issues were identified regarding shower records, and the resident's care plan did not reflect her showering preferences until updated during the inspection. Staff interviews confirmed the lack of consistent shower provision and documentation problems.

The facility failed to provide appropriate treatment and care for Resident #1 by not adequately assessing and monitoring eye drainage and failing to notify the primary physician of outside prescribed treatment. Additionally, the facility failed to maintain a safe environment by not repairing a broken handicap-accessible door to the smoking patio in a timely manner, resulting in falls and injuries to residents.

The facility failed to ensure timely administration of scheduled pain medications for three residents, failed to obtain necessary orders and follow-up for hearing services for one resident, and failed to properly label and remove expired or discontinued medications in medication carts and storage rooms.

The complaint involved substantiated sexual abuse of Resident #51 by Resident #6. The investigation included interviews with staff and residents, review of care plans, and observations. The facility took corrective actions including supervision and staff training. The APS case was closed as the facility was deemed able to provide necessary care and prevent recurrence.

The facility substantiated the sexual abuse of Resident #51 by Resident #6 after investigation. The facility implemented one-to-one supervision, updated care plans, conducted staff education, and initiated a behavioral contract to prevent further incidents.

The complaint investigation focused on Resident #1's blood sugar management. The resident was hospitalized twice due to hyperglycemia, once on 10/18/23 and again two weeks later on 11/2/23. The facility failed to monitor blood glucose levels consistently and did not report abnormal levels to the physician as required. The resident's blood sugar checks were discontinued from 10/27/23 without proper physician notification. The facility submitted a letter from the primary care physician confirming the nurses followed standing orders but acknowledged the facility's failure to monitor blood glucose levels led to hospitalization.

The facility failed to consistently monitor blood glucose levels for Resident #1, who had diabetes and was on diabetic medication. This failure resulted in multiple hospitalizations due to hyperglycemia and related complications. The facility's diabetic management policy and physician orders were not adequately followed, and abnormal blood sugar levels were not reported timely to the physician.

The complaint investigation found that Resident #3 had an unwitnessed fall that was not properly investigated by the facility. The resident had bruising and did not report the fall timely. The facility had no abuse allegations substantiated and confirmed the resident's history of falls and forgetfulness. The investigation revealed gaps in care planning and post-fall assessments.

The facility failed to investigate an unwitnessed fall of Resident #3, who had bruising and did not report the fall in a timely manner. The care plans lacked specific interventions for monitoring bruising and timely fall reporting. The facility had a performance improvement project (PIP) for falls but did not complete required post-fall assessments for this incident. Interviews and record reviews confirmed minimal harm with no evidence of abuse.

The complaint investigation focused on grievances by Resident #27 and Resident #71, including failure to address Resident #27's grievance about the nursing home administrator's rude behavior and failure to follow up on Resident #71's food service complaints. The investigation included interviews with residents, legal representatives, staff, and review of records. The facility failed to document or resolve grievances appropriately and did not provide timely or adequate responses to resident concerns.

The facility failed to properly address resident grievances and dignity concerns, administer oxygen therapy according to physician orders, maintain safe food storage and sanitation in nurse unit refrigerators, and provide sanitary peri care and skin assessments. Several deficiencies were noted including lack of grievance follow-up, oxygen not administered as ordered, improper food storage temperatures and cleanliness, and inadequate infection control during resident care.

The complaint investigation substantiated that Resident #25 touched Resident #51's breast without consent. Resident #25 was difficult to interview due to dementia and lack of memory of the event. The facility supported Resident #51 to feel safe in the community.

The facility substantiated abuse of Resident #51 by Resident #25 involving inappropriate touching. Additionally, the facility failed to maintain proper infection prevention and control by not ensuring the use of gloves and gowns during COVID-19 PCR swab collection for Residents #49 and #53.