Broadway Nursing & Rehabilitation

designed to screen and train employees, protect residents, and to ensure a standardized methodology

Reporting/ResponseD.

The Facility will report allegations of abuse, neglect, exploitation,

that qualify as a crime.

See AN - 01 - Form E - Initial Report - Facility Reported Incidents.i.

Immediately, but no later than 2 hours after forming the suspicion - if the alleged violation involves abuse or results in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman (if applicable per state regulation).

See AN - 01 - Form G - Crosswalk of Abuse Reporting Requirements.ii. No later than 24 hours after forming the suspicion - if the alleged violation (e.g., misappropriation of property, neglect) does not involve abuse and does not result in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman (if applicable per state regulation).

See AN - 01 - Form G - Crosswalk of Abuse Reporting Requirements.

455467 03/27/2026

Broadway Nursing & Rehabilitation 8223 Broadway San Antonio, TX 78209

not dated.

The ADM stated Resident #2's, Resident #4's and Resident #5's NP's progress notes for all

policy Physician Services & Visits, dated 8/20/20, 08/2020, read in relevant part Physician Services

participation in the resident's assessment and careplanning, monitoring changes in resident's medical status, and providing consultation ortreatment when called by the FacilityB.

The Attending Physician must:i.

Evaluate the resident as needed and at least every 30 days for the first 90 daysafter admissions, and at least once every 60 days thereafter unless there is analternate schedule or state specific requirement.

The Attending Physician willdocument the visits in the resident's health record.

II.

Patient diagnosesA.

Provide advice, treatment and determination of appropriate level of care needed for eachpatient.B.

Providing written and signed orders for diet, care, diagnostic tests and treatment ofpatients by others with the exception of influenza and pneumococcal vaccines, which maybe administered after an assessment for contraindications.C.

Health record progress notes and other appropriate entries in the patient's healthrecords.i.

Physician orders and progress notes shall be maintained in accordance withcurrent OBRA regulations and Facility policy.

455467 03/27/2026

Broadway Nursing & Rehabilitation 8223 Broadway San Antonio, TX 78209

Review of progress note for Resident #1 dated 3/3/26 at 06:52 AM read Night nurse (LVN A) stated he sent results to NP pending response.

Review of Resident #1's progress notes revealed no other documentation related to Resident #1's critical lab was entered by LVN A.

Review of Resident #1's assessments for March 2026 revealed there was not a change of condition assessment in response to Resident #1's critical lab value of C02, dated 3/2/26.

Interview on 3/26/25 at 10:55 AM with LVN B revealed she called the NP on 3/3/26 around breakfast time and the NP did not provide any new orders. LVN B stated she did not enter a progress note after contacting the NP.

She stated she must have forgotten to enter the note.

She stated it was important to document so that other nursing staff knew the NP had been contacted and there were no new orders.

She stated other nursing staff would not know the exact status in response to the critical lab.

Telephone interview on 3/26/26 at 4:58 PM with LVN A revealed he did not remember the details about receiving a critical lab for Resident #1 if he wrote any notes.

Interview on 3/27/26 at 9:30 AM with the DON revealed he talked with LVN A about what he did in response to receiving the critical lab for Resident #1.

The DON stated LVN A reported he assessed the resident and she was in stable condition and he texted the NP and himself.

The DON stated LVN A acknowledged he did not complete documentation reflecting what he did to ensure the residents safety. He stated communication was a form of coordination of care which was important to ensure Resident #1 received the care and services she needed.

Review of facility policy Change of Condition Notification, dated 01/2025, read in relevant part VI.

DocumentationA. A Licensed Nurse will document the following:i.

Date, time, and pertinent details of the incident and the subsequent assessmentin the Nursing Notes.ii.

The time the Attending Physician was contacted, the method by which he wascontacted, the response time, and whether or not orders were received.iii.

The time the family/responsible person was contacted.iv.

Update the Care Plan to reflect the resident's current status.v.

The incident and brief details in the 24-Hour Report.