Inspection Reports for
Broadway House for Continuing Care
298 Broadway, Newark, NJ 07104, USA, NJ, 07104
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7.8 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
50% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
83% occupied
Based on a February 2025 inspection.
Occupancy rate over time
Notice
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and to explain their rights related to their health information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Renewal
Census: 65
Capacity: 78
Deficiencies: 5
Date: Feb 26, 2025
Visit Reason
A Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health (NJDOH), Health Facility Survey and Field Operations. The survey included complaint investigations NJ168872 and NJ182337.
Complaint Details
Complaint numbers NJ168872 and NJ182337 triggered part of the survey. The complaint investigation substantiated issues of abuse and neglect involving resident R3 and R119, including physical altercations and failure to protect residents. Bed hold policy failures were also related to complaint findings.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, for long term care facilities based on the recertification and complaint visit. Deficiencies were identified related to freedom from abuse and neglect, bed hold policy, infection prevention and control, staffing ratios, water management, and life safety code violations.
Deficiencies (5)
Failure to ensure residents were free from abuse, neglect, misappropriation, and exploitation.
Failure to provide notice of bed hold policy before or upon transfer of residents to hospital or therapeutic leave.
Infection prevention and control program was incomplete and inconsistent with current standards, including failure to conduct annual review and maintain adequate water management program.
Failure to maintain required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey.
Life Safety Code deficiencies including failure to ensure proper panic hardware on fire rated door, sprinkler system installation issues, portable fire extinguisher servicing, and incomplete fire drills.
Report Facts
Survey Census: 65
Total Capacity: 78
Sample Size: 21
Supplemental Residents: 9
Deficiency Severity SS=D: 2
Deficiency Severity SS=F: 3
Staffing Deficiency Counts: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN)1 | Licensed Practical Nurse | Witnessed and reported abuse incident involving residents R3 and R119. |
| Director of Nursing | Director of Nursing | Responsible for conducting interviews and audits related to abuse prevention and bed hold policy compliance. |
| Maintenance Director | Maintenance Director | Responsible for ensuring fire safety equipment and HVAC inspections and maintenance. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 26, 2025
Visit Reason
The inspection was conducted following complaints related to resident-to-resident abuse, failure to provide bed hold notices for residents discharged to the hospital, and inadequate infection prevention and control program regarding water management.
Complaint Details
The complaint investigation substantiated that Resident 119 physically abused Resident 3. The facility failed to provide bed hold notices to two residents discharged to the hospital. The water management program was inadequate, lacking required documentation and posing infection risks.
Findings
The facility failed to protect a resident from abuse by another resident, failed to provide timely bed hold notices to residents discharged to the hospital, and did not have an adequate water management program consistent with ASHRAE guidelines, creating potential risks for Legionella infection.
Deficiencies (3)
F 0600: The facility failed to ensure residents were free from abuse when Resident 119 physically abused Resident 3. The incident was verified and resulted in one-on-one supervision and transfer of Resident 119 for crisis intervention.
F 0625: The facility failed to notify two residents or their representatives in writing about bed hold policies within 24 hours of emergent hospital transfers, increasing the risk that residents would not know to request a bed hold.
F 0880: The facility failed to implement an adequate water management program consistent with ASHRAE guidelines, lacking a diagram or description of the building's water system, which increased the risk of Legionella infection for vulnerable residents.
Report Facts
Residents sampled: 21
Residents affected by abuse deficiency: 1
Residents affected by bed hold notice deficiency: 2
Residents affected by infection control deficiency: 65
BIMS score of Resident 3: 11
BIMS score of Resident 119: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Witnessed and reported resident-to-resident abuse incident |
| Director of Nursing | Director of Nursing | Conducted investigation, interviewed staff and residents, and stated expectations for resident protection |
| Business Office Assistant | Business Office Assistant | Confirmed facility did not provide bed hold policy to residents or representatives |
| Maintenance Director | Maintenance Director | Reported lack of water system diagram and responsibility for water temperature testing |
| Administrator | Interim Administrator | Stated expectations to monitor water management program |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 1
Date: May 18, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint #NJ00164204 regarding the facility's failure to implement interventions to prevent an elopement and follow the facility's policy for one resident.
Complaint Details
Complaint #NJ00164204 was substantiated. The facility failed to prevent Resident #1 from eloping by leaving the facility unescorted despite policy requiring escorts for medical appointments. Staff failed to verify pass status and appointment schedules, and the resident ultimately signed out against medical advice.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, due to failure to ensure adequate supervision and prevent accidents, specifically failing to prevent Resident #1 from eloping by leaving the facility unescorted for a medical appointment, contrary to facility policy. Multiple staff members failed to follow escort requirements and verify pass status, resulting in the resident leaving unescorted and subsequently signing out against medical advice.
Deficiencies (1)
Failure to implement interventions to prevent an elopement and follow facility policy for Resident #1, who left the facility unescorted for a medical appointment.
Report Facts
Census: 63
Sample Size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN/UM | Registered Nurse/Unit Manager | Allowed Resident #1 to leave the facility unescorted for a medical appointment, failed to follow facility policy |
| SP #1 | Security Personnel | Allowed Resident #1 to leave unaccompanied without verifying pass status or appointment schedule |
| RN #1 | Registered Nurse | Assigned nurse for Resident #1 who allowed unescorted departure and failed to verify escort requirements |
| DON | Director of Nursing | Explained facility procedures and acknowledged staff failures in following escort policies |
| Administrator | Facility Administrator | Stated expectation that all staff follow pass or escort requirements |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 18, 2023
Visit Reason
The inspection was conducted in response to a complaint regarding the facility's failure to implement interventions to prevent an elopement and to follow the facility's policy for Resident #1.
Complaint Details
Complaint #NJ00164204 was substantiated. The investigation confirmed that Resident #1 eloped on 5/12/23 due to staff failing to follow escort policies and procedures.
Findings
The facility staff failed to follow the policy requiring escorts for Resident #1 during radiation therapy appointments, resulting in the resident leaving the facility unescorted and eloping. Multiple staff members acknowledged not following the escort policy, and the resident ultimately signed out against medical advice.
Deficiencies (1)
F 0689: The facility failed to ensure the nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents, as staff allowed Resident #1 to leave unescorted contrary to policy.
Report Facts
Date of elopement: May 12, 2023
Date of inspection: May 18, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN/UM | Registered Nurse/Unit Manager | Allowed Resident #1 to leave the facility without an escort on 5/10/23 and failed to follow facility policy. |
| SP #1 | Security Personnel | Allowed Resident #1 to leave unaccompanied on 5/12/23 without verifying pass status or appointment calendar. |
| RN #1 | Registered Nurse | Assigned nurse on 5/12/23 who allowed Resident #1 to leave unescorted and failed to verify escort requirements. |
| DON | Director of Nursing | Provided interviews confirming policy violations and staff failures. |
| Administrator | Administrator | Stated all staff are expected to follow pass or escort requirements. |
Inspection Report
Annual Inspection
Census: 63
Capacity: 74
Deficiencies: 9
Date: Dec 22, 2022
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to timely transmission of resident assessments, accident hazards and supervision, drug labeling and storage, nurse aide in-service training, staffing ratios, life safety code violations including sprinkler system installation, smoke barrier penetrations, fire drills, and smoking regulations.
Deficiencies (9)
Facility failed to timely transmit a resident's Minimum Data Set (MDS) assessment to CMS within required timeframe.
Facility failed to follow smoking care plan interventions, complete safe smoking evaluations, and accurately code resident's smoking status on MDS.
Facility failed to remove expired controlled medications from electronic backup supply machine.
Facility failed to ensure Certified Nursing Aides received 12 hours of mandatory annual in-service training including abuse training.
Facility failed to maintain required minimum direct care staff to resident ratios for day shift.
Facility failed to ensure building was protected throughout by an approved automatic sprinkler system; storage room lacked sprinkler coverage.
Facility failed to ensure penetrations in smoke barriers were protected by a system or material capable of restricting smoke transfer.
Facility failed to conduct fire drills quarterly on each shift.
Facility failed to ensure ashtrays of noncombustible material and safe design and a metal container with self-closing cover device were available in smoking area.
Report Facts
Census: 63
Total Capacity: 74
Deficient CNA staffing days: 14
Required CNA to resident ratio: 8
Observed CNA staffing: 3
Fire drills conducted on 1st shift: 10
Fire drills conducted on 2nd shift: 1
Fire drills conducted on 3rd shift: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #22 | Resident | Named in deficiency for untimely MDS transmission |
| Resident #19 | Resident | Named in deficiency for smoking care plan and safety issues |
| CNA #1 | Certified Nursing Aide | Named in deficiency for incomplete in-service training |
| MDS Coordinator | Named in deficiency for MDS transmission and coding | |
| Director of Nursing | Named in monitoring and corrective action plans | |
| Staffing Coordinator | Named in deficiency for staffing ratio issues | |
| Director of Building Services | Named in deficiency for sprinkler system observation | |
| Director of Maintenance | Named in deficiencies related to sprinkler system and smoke barrier penetrations | |
| Director of Plant Operations | Named in corrective actions for fire drills and smoking regulations | |
| Nurse Educator | Named in deficiency for nurse aide training |
Inspection Report
Routine
Deficiencies: 4
Date: Dec 22, 2022
Visit Reason
The inspection was conducted to assess compliance with federal and state regulations regarding resident care, medication management, smoking safety, and staff training at Broadway House for Continuing Care.
Findings
The facility was found deficient in timely transmission of resident assessment data, failure to follow smoking safety protocols including inaccurate coding and incomplete evaluations, improper medication storage with expired controlled drugs, and inadequate annual in-service training for a Certified Nursing Aide.
Deficiencies (4)
F 0640: The facility failed to timely transmit a resident's Minimum Data Set (MDS) to CMS within the required 14 days after assessment completion.
F 0689: The facility failed to follow smoking care plan interventions, complete safe smoking evaluations, and accurately code a resident's smoking status on the MDS.
F 0761: The facility failed to remove expired controlled medication (Oxycodone) from the active backup supply in medication storage.
F 0947: The facility failed to ensure a Certified Nursing Aide received the mandatory 12 hours of annual in-service training including abuse prevention.
Report Facts
Residents reviewed for MDS transmission: 18
Residents reviewed for smoking: 1
Expired Oxycodone tablets: 2
CNA training hours completed: 6.5
Required CNA training hours: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Aide | Named in deficiency for incomplete mandatory annual training. |
| MDS/Coordinator | Interviewed regarding late MDS submission and inaccurate smoking status coding. | |
| Registered Nurse/Unit Manager | RN/UM | Observed expired medication and interviewed about medication storage. |
| Licensed Practical Nurse | LPN | Participated in medication inventory and interviewed about smoking assessments. |
| Nurse Educator | NE | Interviewed regarding CNA training deficiencies. |
| Chief Operating Officer | COO | Confirmed medication policy and CNA training deficiencies. |
| Activities Director | AD | Interviewed about smoking evaluations and resident compliance. |
Inspection Report
Abbreviated Survey
Census: 84
Deficiencies: 0
Date: Nov 30, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 5
Inspection Report
Routine
Census: 64
Deficiencies: 0
Date: Aug 11, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Routine
Census: 64
Deficiencies: 0
Date: Mar 22, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 6
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 4
Date: Feb 25, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to failure to maintain professional nursing standards during medication administration, failure of the consultant pharmacist to identify medication irregularities, failure to maintain kitchen sanitation, and failure to properly dispose of garbage and refuse.
Deficiencies (4)
Facility failed to maintain professional standards of nursing practice following a physician's order for parameters during medication administration.
Consultant pharmacist failed to identify medication irregularities and document recommendations for residents on certain medications.
Facility failed to maintain kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances.
Facility failed to properly dispose and maintain waste in the garbage compactor area.
Report Facts
Census: 60
Sample size: 16
Inspection Report
Routine
Deficiencies: 4
Date: Feb 25, 2021
Visit Reason
The inspection was conducted to evaluate compliance with professional nursing standards, medication regimen review, kitchen sanitation, and waste disposal practices at the nursing facility.
Findings
The facility failed to maintain professional nursing standards in medication administration, failed to identify contraindications in medication regimen reviews by the Consultant Pharmacist, and did not maintain kitchen and garbage disposal areas in a sanitary manner, posing potential risks for resident safety and foodborne illness.
Deficiencies (4)
F 0658: The facility failed to maintain professional nursing standards by not properly verifying vital signs before administering medication with physician-ordered parameters for Resident #56.
F 0756: The Consultant Pharmacist failed to identify contraindications in opioid-dependent Resident #62's medication regimen involving Methadone and Percocet during monthly reviews.
F 0812: The facility failed to maintain the kitchen environment and equipment in a sanitary manner, allowing personal items on food condiment shelves, risking contamination.
F 0814: The facility failed to properly dispose and maintain waste in the garbage compactor area, which was littered with soiled items and lacked a clear cleaning policy or agreement.
Report Facts
Doses of Percocet received: 14
Medication dosage: 2.5
Vital sign parameter: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Discussed medication administration standards and Consultant Pharmacist review issues. |
| Consultant Pharmacist | Consultant Pharmacist | Failed to identify contraindications in Resident #62's medication regimen. |
| Dietary Director | Dietary Director | Observed and addressed sanitation issues in the kitchen area. |
| Maintenance Director | Maintenance Director | Interviewed regarding garbage compactor area maintenance responsibilities. |
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