Inspection visit

Health inspectionAugust 24, 2022

BROADMOOR MEDICAL LODGECMS #6763352 citations on this visit

2 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff for one (Hall 400) of three halls and two of three (main dining and bistro dining area) dining areas observed for environment, in that: The facility failed to ensure furniture (chairs) were in good repair for Rooms #407, #408, #412, #414, #415, and #417, and in the main dining and bistro dining area. These failures could place residents at risk for diminished quality of life due to the lack of a well-kept furniture. Findings included: An observation of Room#415 on 08/21/22 at 10:36 a.m., revealed a straight back sitting chairs seat bottom was frayed and torn with the foam exposed. An observation of room [ROOM NUMBER] on 08/21/22 at 10:42 a.m., revealed a straight back straight back sitting chairs seat bottom was frayed and torn with the foam exposed. An observation of the main dining area on 08/21/22 at 10:50 a.m., revealed six dining chairs seat bottoms was frayed and torn with the foam exposed. An observation of the Bistro dining area on 08/21/22 at 11:05 a.m., revealed four dining chairs seat bottoms was frayed and torn with the foam exposed. An observation of room [ROOM NUMBER] on 08/21/22 at 11:15 a.m., revealed a straight back sitting chairs seat bottom was frayed and torn with the foam exposed. An observation of room [ROOM NUMBER] and interview on 08/21/22 at 11:30 a.m., revealed a straight back sitting chairs seat bottom was frayed and torn with the foam exposed. The family member of Resident #77 was visiting and stated she had asked for another chair to sit in, and the staff provided another chair that was torn. I told the staff I ws not going to sit in a torn chair. The family member said , since they were going to be here every day they had just brought their own folding chair. An observation of room [ROOM NUMBER] and interview on 08/22/22 at 11:45 a.m., revealed a straight back sitting chairs seat bottom was frayed and torn with the foam exposed. Resident #149 stated she was aware the chair was torn, and it did not look nice and she would like it to look nicer, but her (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 676335 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 visitors usually stood when they came to visit, or we go outside to the gazebo area and visit. Level of Harm - Minimal harm or potential for actual harm An observation of the administrator's office on 08/21/22 at 12:00 p.m., revealed two straight back sitting chairs seat bottom was frayed and torn with the foam exposed. Residents Affected - Some An observation of room [ROOM NUMBER] and interview on 08/22/22 at 1:00 p.m., revealed Resident #153 and his wife were visiting in his room. Resident #153 stated his wife had to get the staff to provide a chair to sit in that did not have a torn bottom. He stated the chair she was sitting in stayed in the room, because the other one was all torn up, just look at it. Interview on 8/21/22 at 10:15 a.m., LVN E revealed if something was broken or needed to be repaired the staff wrote it in the maintenance log. LVN E stated the log was located at the nurse's station. LVN E stated if the furniture was broken she would let the maintenance man know, by writing it in the book at the nurse's station. LVN E stated she was not aware any of the chairs broken, some of them are worn looking, they could use some new material. The LVN said she had not reported to anyone about the worn chairs. In an observation and interview on 08/21/22 at 12:50 p.m., CNA F revealed if something was broken it would be written in the maintenance log at the nurse's station. The CNA went to the nurse's station and the book was at the nurse's station. CNA F stated some of the chairs are worn and if the families or residents complain she finds a chair that does not have material worn out on the bottom. The CNA stated she had not told anyone. Interview on 08/23/22 at 1:00 p.m., the Administrator revealed he was aware that the chairs used for dining and in resident's rooms, needed repair. The Administrator said he was going to have few chairs bottoms reupholstered at a time, as it was expensive, but he had not gotten that started. The Administrator stated he would have the maintenance man remove all the chairs right away and he would complete a quality assurance plan on the replacement of the chairs, he did not want the residents or the families to sit in chairs that required repair. The Administrator stated he was unaware of any complaints concerning the chairs. Review of the Maintenance log report reflected for the months of March, April, May, June and July of 2022, there was no documentation related to the condition of the chairs. The Maintenance Director was unavailable during the visit. Review of the Policy/Procedure Cleaning/Repairing Carpeting and Cloth Furnishings, dated December 2009 reflected .cloth furnishing shall be .repaired promptly .Upholstered furniture shall be kept in good repair and replaced if torn excessively . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676335 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to Residents Affected - Few store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. 1.The facility failed to ensure food items in the refrigerator were labeled and stored in accordance with the professional standards for food service and the facility's policy. 2.The facility failed to discard items stored in the refrigerator or dry storage that were not properly sealed/secured, damaged or past the 'best use by', consume by or expiration dates. These failures could place residents at risk for food-borne illness and cross contamination. Findings included: Observations of the walk-in refrigerator on 08/21/22 at 9:39 AM -On right shelf, next to door. In a zip top bag, labeled 08/19/20, there was some shredded cheese in its original package that was open to air inside of the zip top bag that was also open to air. There was no item description or use by date reflected. -Diced Honeydew in medium metal container, covered in plastic wrap, dated 8/7/22, no item description or use by date. -Chili in large metal container, covered in plastic wrap, dated 8/16/22 with no use by date. -Vegetable cream-based soup in small metal container, dated 08/18/22, no item description or use by date. -2-4 oz. containers of Peach yogurt, no received date with expiration date of 08/20/22. -On 2nd shelf in the back, was ground meat in a small metal container, no description label or a prepared/opened date or a use by date. - 2 trays of 50-4oz. clear cups with brown liquid with plastic lids on top, on rack, in rear right side of fridge, with no labels on trays of when pulled/prepared date, item description or use by date. -10 bowls of pureed angel food cake with strawberry sauce, there was no label of preparation date, no item description, no use by date, no covering. -There were 3 more trays with a total of 66 bowls of Angel food cake with strawberry sauce, no item description, preparation date, no covering, no use by date. Observations of the dry storage room on 08/21/22 at 10:23 AM revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676335 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm -2 bags of [NAME] Gravy mix opened then sealed in plastic wrap, no item description, no open date or use by date reflected. - 1 bag of mashed potato flakes opened, sealed in plastic wrap, no item description, no date opened or use by date reflected. Residents Affected - Few -1 large bag of powdered sugar opened, placed in a zip top bag, no label for item description, no opened date or use by date reflected. - 1 bag of Pepper Biscuit gravy mix opened, then sealed in plastic wrap, no label of item description, no opened date or use by date. - 842 oz containers of Oats, had no received dates. -1 large bag of Grits dated 11/23/21 with an expiration 4/14/22. -2 Boxes of grits dated 12/7/21 with expiration 5/2/22. Observation of reach-in refrigerator on 08/21/22 at 9:44 AM revealed the following: 1-8oz container of 1/3 less fat cream cheese block that expired on 08/12/22. Observation of freezer on 08/21/22 at 10:12 AM revealed the following: -There were two stacks of boxes stacked on the floor to the left side freezer door. One stack was 2 small boxes tall and the other stack 3 boxes high. -There was a large ice formation on the top and 2nd box of the 2 box stack attaching the two boxes and another formation starting on the 3 box stack. Observations and interview of the kitchen on 08/21/22 at 9:39 AM revealed the following: -There was one tray of snacks sitting under the prep table on top of the juice mix boxes, that connected to juice machine. The snack tray was not labeled to reflect the date the snacks were pulled. -A Hanging rack over the food prep table with cooking utensils hanging from it, had greasy residue build up. -The Cleaning Schedule for 8/1/22-8/8/22 was posted on glass of Managers office, and there were several areas left uninitialed. There was not a current cleaning schedule posted -1 potato sitting on top of the steam table, unwrapped and unlabeled, no pulled or use by date. In an interview on 08/21/22 at 10:05 AM, the Dietary Manager stated leftovers are held in the fridge for 3 days. She said, my expectations of staff is to put open dates on dry goods. She said, We have been short staff since January 2022 I have been working as the [NAME] too. She stated it was everyone's job to label food items when they come in. Observation of Lunch Service on 08/24/22 at 11:06 AM revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676335 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Entered kitchen, staff already starting to plate lunch meals. Staff present: Dietary Manager, Dietary Aide C, [NAME] A, and Dietary Aide D. Dietary manager stated Dietary Aide D is new. Dietary Aide D said, I have been here for a week and a half -Trash receptacle for the hand washing sink, next to the walk-in refrigerator, has items other than paper towels inside. There are plastic bags from the mash potato flakes and gloves in the trash receptacle. -At 11:16 AM Dietary Aide D went from prepping trays to starting to break apart the dinner rolls, without removing or changing gloves. Review of the Facility's Nutrition Services Food Storage Policy and Procedure, Policy Number: 03.003; Date Approved: October 1, 2018; Date Revised: June 1, 2019; Approved by: [NAME] Odefey MS, RDN, LD, reflected Policy: To ensure that all served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HAACCP guidelines. Procedure: 1. Dry storage rooms . e. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated G. Where possible, leave items in the original cartons placed with the date visible. Use the first-in, first-out (FIFO) rotation method. Date packages and place new items behind existing supplies, so that the older items are used first. 2. Refrigerators . e. Use all leftover within 72 hours. Discard items that are over 72 hours old 3. Freezers . c. Store all foods on racks or shelves off the floor. d. Do not over stock the freezer and leave space between items to further improve air circulation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676335 If continuation sheet Page 5 of 5

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Citations

2 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0584GeneralS&S Epotential for harm
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
0812GeneralS&S Dpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

FAQ · About this visit

Common questions about this visit

What happened during the August 24, 2022 survey of BROADMOOR MEDICAL LODGE?

This was a inspection survey of BROADMOOR MEDICAL LODGE on August 24, 2022. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at BROADMOOR MEDICAL LODGE on August 24, 2022?

Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receivin..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

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Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·August 24, 2022