The Broadway Nursing And Rehabilitation Ctr
THE BROADWAY NURSING AND REHABILITATION CTR in LOCKPORT, LA — inspection on February 17, 2025.
Found 9 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
no documented evidence Resident #9's physician was notified when the above mentioned medication
In an interview on 02/12/2025 at 2:04PM, S4Corporate Compliance Officer indicated Resident #9's
195583 02/17/2025
The Broadway Nursing and Rehabilitation Ctr 7534 Highway 1 Lockport, LA 70374
Review of the facility's undated Grievance policy and procedure revealed, in part, the facility administrator or designee will act as the grievance official, and all grievances made by a resident or resident's family would be documented on the grievance form by the grievance official.
Further review revealed the grievance form would include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of pertinent findings or conclusions regarding the resident's concerns, a statement as whether the grievance was confirmed or not confirmed, corrective action taken by the facility as a result of the grievance, and the date the written decision was issued.
Review of the facility's Grievance Log from 11/2024 to 2/2025 revealed, in part, Resident #13 filed a nurse-related grievance on 01/05/2025, and the grievance was resolved on 01/06/2025.
In an interview on 02/11/2025 at 1:50PM, S4Coporate Compliance Officer indicated S8Social Service Director (SSD) was the facility's grievance official and S1Administrator was responsible for overseeing and signing all grievance reports.
Review of Resident #13's Grievance Report revealed, in part, Resident #13's above mentioned grievance was not signed by S1Administrator.
Further review of Resident #13's grievance report revealed there was no documented statement as whether the grievance was confirmed or not confirmed, there was no documented evidence of a resolution of Resident #13's grievance, there was no documented evidence of action taken by the facility as the result of the grievance, and there was no documented evidence the facility notified Resident #13 and/or Resident #13's responsible party of a resolution to Resident #13's grievance.
In an interview on 02/11/2025 at 2:30PM, S8SSD indicated she was not aware of the resolution and had not received the investigation completed by S1Administrator for Resident #13's Grievance Report dated 01/06/2025. S8SSD further indicated Resident #13's grievance investigation and resolution were not properly documented on the Grievance Report form and they should have been.
There was no documented evidence, and the facility did not present any documented evidence, Resident #13's above mentioned Grievance Report was properly documented.
In an interview on 02/12/2025 at 1:10PM, S1Administrator indicated he did not submit the investigation of Resident #13's grievance dated 01/06/2025 to the grievance official. S1Administrator further indicated Resident #13's Grievance Report did not include a resolution on the Grievance Report form, did not include the notification of Resident #13 or Resident #13's responsible party of the resolution, and was not signed by the administrator. S1Administrator confirmed Resident #13's above mentioned written Grievance Report was not properly completed by the grievance official and it should have been.
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The Broadway Nursing and Rehabilitation Ctr 7534 Highway 1 Lockport, LA 70374
Review of the facility's undated Abuse and Neglect policy revealed, in part, a type of Abuse included Neglect.
Further review revealed, neglect was defined the failure of the facility, its employees, or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish or emotional distress.
Further review revealed neglect occurred when the facility was aware of, or should have been aware of, goods or services that a resident (s) required but the facility failed to provide them to the resident(s), that had resulted in or may had resulted in physical harm, pain mental anguish, or emotional distress.
Further review revealed the facility administrator or designee shall complete a report to the mandated state agency according to state guidelines upon notification of alleged abuse.
Review of a facility document titled Employee Status Change revealed, in part, S5Unlicensed Personnel had a status change from Certified Nursing Aide to Licensed Practical Nurse effective 11/20/24.
Review of S5Unlicsened Personnel's personnel record revealed, in part, no documented evidence S5Unlicesened Personnel had a current valid Louisiana Practical Nurse License.
Review of S5Unlicensed Personnel's time records from 11/20/2024 through 01/23/2025 revealed S5Unlicensed Personnel worked 37 shifts as a LPN.
Review the facility's investigative report for neglect dated 01/31/2025 at 11:33AM revealed, in part, on 01/24/2024, S7Team Member Specialist/Human Resources was informed by the Louisiana State Board of Nursing that S5Unlicensed Personnel had not passed the NCLEX-PN (a standardized test that a nurses must pass to become a LPN.) Further review revealed S5Unlicensed Personnel began her training as a facility LPN on 11/20/2024 and started working as a facility LPN without direct supervision on 12/12/2024.
Further review revealed this incident had occurred on 01/24/2025 at 12:18PM and was reported to the Louisiana Department of Health through the Statewide Incident Management System (SIMS) on 01/31/2025 at 11:33AM.
In an interview on 02/17/2025 at 10:15AM, S1Administrator indicated on 01/24/2025 S7Team Member Specialist/Human Resources informed him S5Unlicensed Personnel did not have a valid Louisiana state nursing license. S1Administrator further indicated there was a likelihood of serious injury, serious harm, serious impairment or death due to having an unlicensed personnel providing nursing services. S1Administrator further indicated a report should have been entered into the SIMS within 24 hours of the discovery of the incident.
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The Broadway Nursing and Rehabilitation Ctr 7534 Highway 1 Lockport, LA 70374
- On 01/08/2025 at 9:31PM, Resident #16's blood sugar was 313 mg/dL.
Further review revealed no documented evidence, and the facility did not present any documented evidence, Resident #16's physician was notified when Resident #16's blood sugar was greater than 250 mg/dL on the above mentioned dates, and should have been.
In an interview on 02/12/2025 at 2:46PM, S2Director of Nursing confirmed the facility had no evidence Resident #16's physician was notified when Resident #16's blood sugar was greater than 250 mg/dL on the above mentioned dates, and should have been.
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The Broadway Nursing and Rehabilitation Ctr 7534 Highway 1 Lockport, LA 70374
Review of the facility's time sheets dated 02/05/2025 to 02/06/2025 for the 10:00PM to 6:00AM shift revealed, in part: -On 02/05/2025, from 10:35PM to11:58PM, S54CNA, S64CNA, S63CNA, S83CNA S85CNA, S86CNA, and S87CNA were clocked in for a total of 7 CNAs working in the facility. -On 02/05/2025, from 11:59PM to 4:29AM on 02/06/2025, S85CNA, S86CNA, S64CNA, S63CNA, S83CNA, and S54CNA were clocked in for a total of 6 CNAs working in the facility. -On 02/05/2025, from 4:30AM to 4:50AM on 02/06/2025, S85CNA, S86CNA, S64CNA, S63CNA, S83CNA, S54CNA, and S88CNA were clocked in for a total of 7 CNAs working in the facility.
Review of the facility's time sheets dated 02/06/2025 to 02/07/2025 for the 10:00PM to 6:00AM shift revealed, in part: -On 02/06/2025, from 10:07PM to 10:27PM, S63CNA, S77CNA, S64CNA, S85CNA, S54CNA, and S86CNA were clocked in for a total of 6 CNAs working in the facility.
There was no documented evidence, and the facility did not present any documented evidence, any other CNAs worked during the above mentioned time frames.
In an interview on 02/17/2025 at 11:59AM, S6Chief Operations Officer acknowledged the facility should be staffed according to the facility assessment.
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The Broadway Nursing and Rehabilitation Ctr 7534 Highway 1 Lockport, LA 70374
Count Sign Sheet for Medication Cart c, S14Agency LPN did not sign the February 2025 Narcotic
Sign Sheet for Medication Cart b on the above mentioned dates and times, as required. S2DON further indicated anyone who reconciled the medication carts' narcotics should have signed the Narcotic Count Sign Sheet.
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The Broadway Nursing and Rehabilitation Ctr 7534 Highway 1 Lockport, LA 70374
administration concerns or other nursing concerns on 01/30/2025.
jeopardy to resident health or c.
Full facility wide audit started on 01/24/2025 on all nurses to ensure active license in place. safety d. In-service on reporting wrongdoing was completed by S1Administrator, S2DON, S7TMS, and staff
e.
Audits were completed on 01/31/2025 of resident's electronic medical records documentation who received care from S5Unlicensed Personnel while S5Unlicensed Personnel worked in the capacity as a LPN to ensure no harm occurred.
- The facility would monitor its performance to ensure solutions were sustained by completing the
- Plan of Correction to be completed by 01/31/2025.
following: a. S7TMS to verify licensure prior to nurse hired or role change if currently working. S2DON would be provided with a copy for double verification at the facility level. b. S4Corporate Compliance Officer to audit weekly for compliance for three months and annually.
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The Broadway Nursing and Rehabilitation Ctr 7534 Highway 1 Lockport, LA 70374
jeopardy to resident health or by 01/31/2025. safety e.
Audits were completed on 01/31/2025 of resident's electronic medical records documentation who
a LPN to ensure no harm occurred.
- The facility would monitor its performance to ensure solutions were sustained by completing the
- Plan of Correction to be completed by 01/31/2025.
following: a. S7TMS to verify licensure prior to nurse hired or role change if currently working. S2DON would be provided with a copy for double verification at the facility level. b. S4Corporate Compliance Officer to audit weekly for compliance for three months and annually.
Review of the facility's undated Administrator Job's Description revealed, in part, the Administrator reported to the Regional Director and was responsible for adopting and enforcing rules and for the healthcare and safety of patients and others.
Review of the facility's undated Director of Nursing's Job Description revealed, in part, the DON reported to the Administrator.
Further review revealed the DON's responsibility was to assist with interviewing, evaluating and selecting new personnel.
Review of the facility's undated Human Resources/Payroll Manager Job Description revealed, in part, the Human Resources/Payroll Manager reported to the Administrator and was responsible for maintenance of all personnel files in compliance with local and federal laws.
Review of S5Unlicensed Personnel's Employee Status Change signed by S7Team Member Specialist (TMS) on 11/20/2024 revealed, in part, S5UnlicensedPersonnel had a title change from Certified Nurse Aide (CNA) to LPN.
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Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 195583 B.
Wing 02/17/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
The Broadway Nursing and Rehabilitation Ctr 7534 Highway 1 Lockport, LA 70374
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.