Broadway Manor Care Center: Nursing Documentation Failures - CA
That omission sits at the center of a complaint inspection completed May 26, 2026, at Broadway Manor Care Center, a skilled nursing facility in Glendale. Federal inspectors found that a charge nurse, identified in records as HLN, failed to give the treating physician the full picture of what she had observed on Resident 1's right upper arm, and then failed to document almost any part of the exchange that followed.
The arm was swollen. There was edema. And there was the green discoloration, one centimeter by one centimeter, visible enough that HLN noticed and remembered it when inspectors interviewed her later. She told them she saw it. She also told them she did not tell Physician 2 about it during the phone call.
What she told the doctor, and what the doctor said back, is largely unrecoverable. HLN told inspectors there was no documentation of the time she placed the call. There was no record of the specific order she received. She did not place a telephone order for monitoring. The call happened, by her own account, and then it effectively disappeared from the medical record.
For a hospice resident, the stakes of incomplete communication and missing documentation are not abstract. Hospice care by its nature involves a careful, ongoing negotiation between what a resident is experiencing and what the care team decides to do about it. Symptoms that might prompt aggressive intervention in another setting are weighed differently. But that weighing requires accurate information. A physician who does not know about a green discoloration on a swollen arm cannot factor it into any decision.
Inspectors reviewed the facility's own policies. The acute condition change protocol, revised in March 2023, described a process in which nursing staff contact the physician based on the urgency of the situation, and the nurse and physician together discuss possible causes, current symptoms, and whether diagnostic tests are warranted. The hospice program policy, also revised in March 2023, stated that the facility is responsible for communicating with the hospice provider and documenting that communication to ensure resident needs are addressed around the clock.
HLN's call to Physician 2 did not meet either standard. The symptom was incomplete. The documentation did not exist.
The inspection classified the violation as causing minimal harm or potential for actual harm, and noted that few residents were affected. Broadway Manor did not receive an immediate jeopardy citation. But the classification describes the regulatory finding, not necessarily the experience of the person whose arm was swollen and green while the nurse who saw it decided, for reasons the record does not explain, not to bring it up.
What Physician 2 would have done with that information, whether it would have changed the monitoring order or prompted a direct evaluation, is something the record cannot answer. The order that was given, whatever it was, was based on a description that left something out. And because HLN did not document the time of the call or the specifics of what was ordered, there is no way to reconstruct the timeline or verify that any follow-through occurred.
Resident 1 was on hospice. The details of their condition beyond the arm, their history, how long they had been at the facility, are not contained in the inspection report. What the report does contain is a nurse who saw something, called a doctor, stayed quiet about part of it, and wrote nothing down.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Broadway Manor Care Center from 2026-05-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 13, 2026 · Our methodology
BROADWAY MANOR CARE CENTER in GLENDALE, CA was cited for violations during a health inspection on May 26, 2026.
That omission sits at the center of a complaint inspection completed May 26, 2026, at Broadway Manor Care Center, a skilled nursing facility in Glendale.
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.