Broadway Nursing & Rehab: Medical Record Failures - TX
The resident, identified in inspection records only as Resident 1, had a CO2 level of 42. The normal reference range is 21 to 31. A reading that far outside normal range is the kind of result that triggers immediate notification requirements and demands a documented response. What inspectors found instead was a chain of incomplete notes and a nurse who said she simply forgot.
The first nurse on the case, LVN A, was working the night shift. At 1:14 a.m., a progress note recorded that Resident 1 had critical lab results and that both the nurse practitioner and the director of nursing had been informed. The resident was described as stable. A second note, entered at 6:52 a.m., stated that LVN A had sent the results to the nurse practitioner and was awaiting a response.
That was the last documentation anyone entered about the critical lab.
No follow-up note. No change of condition assessment. No record of whether the nurse practitioner ever responded, whether new orders were given, or whether Resident 1 was reassessed before the night shift ended.
When inspectors reached LVN A by phone on March 26, he said he did not remember the details of receiving a critical lab for Resident 1 or whether he had written any notes. The director of nursing, interviewed the following morning, said he had spoken with LVN A separately. According to the DON, LVN A told him he had assessed the resident, found her stable, and texted both the nurse practitioner and himself. LVN A acknowledged to the DON that he had not completed any documentation reflecting what he did to ensure the resident's safety.
The morning shift brought a second nurse into the picture. LVN B told inspectors she called the nurse practitioner around breakfast time on March 3 and was told there were no new orders. She did not enter a progress note after that call. "She stated she must have forgotten to enter the note," the inspection report reads.
LVN B understood exactly what that gap meant. She told inspectors it was important to document so that other nursing staff would know the nurse practitioner had been contacted and that no new orders had come back. Without that note, she acknowledged, other staff would not know the exact status of Resident 1 in response to the critical lab.
The director of nursing put it plainly during his interview with inspectors. Communication, he said, was a form of coordination of care, and it was important to ensure Resident 1 received the care and services she needed.
The facility's own policy on change of condition notification, dated January 2025, laid out what licensed nurses were required to document: the date, time, and details of the incident and subsequent assessment; the time the attending physician or nurse practitioner was contacted, the method used, the response time, and whether orders were received; the time family was notified; updates to the care plan; and a brief entry in the 24-hour report.
None of that happened here.
The inspection was triggered by a complaint and conducted on March 27, 2026. Inspectors reviewed records for seven residents and found the documentation failure in one of them. CMS rated the level of harm as minimal harm or potential for actual harm.
What the record cannot show, because no one wrote it down, is what the nurse practitioner said when LVN B called that morning. Whether the elevated CO2 prompted any clinical concern. Whether anyone went back to check on Resident 1 before the shift changed. The notes that exist say she was stable at 1:14 a.m. After that, the file goes quiet.
LVN B said other nursing staff would not know the exact status. She was right. They still don't.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Broadway Nursing & Rehabilitation from 2026-03-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 18, 2026 · Our methodology
Broadway Nursing & Rehabilitation in SAN ANTONIO, TX was cited for violations during a health inspection on March 27, 2026.
The resident, identified in inspection records only as Resident 1, had a CO2 level of 42.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.