Brookdale Galleria

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision for 1 of 8 residents (Resident #1) reviewed for adequate supervision. The facility failed to ensure that Resident #1 received adequate supervision when Resident #1 was able to exit the facility at 1:00am and found by staff on a busy street. An Immediate Jeopardy (IJ) was identified on 3.20.2026. The IJ template was provided to the Administrator on 3.20.2026 at 5:48 p.m. On 3/21/26 at 8:15pm, the Administrator was notified that the IJ was removed; however, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice the comprehensive person-centered care plan and the residents choices 1 of 5 residents (Resident #1) reviewed for quality of care. - The facility failed to ensure Resident #1 received orders for crushed medications as required after a speech therapy evaluation diagnosed him with dysphagia (difficulty swallowing) on 09/03/25 until 10/30/25.- The facility failed to ensure Resident #1 had orders to crush medications before administering crushed medications. This failure could result in resident's not receiving the care necessary, choking, and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 8 resident (Resident #1) reviewed for accuracy of assessments. - The facility failed to accurately document Resident #1's dysphagia (difficulty swallowing) that required a modified diet and crushed medications in his diagnosis and MDS. This failure could place residents at risk of inaccurate assessments, which could compromise their plan of care .

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment describing services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Residents #1) reviewed for comprehensive care plans. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preference for 1 of 5 residents (Resident #2) reviewed for respiratory care. - The facility failed to ensure to change the water in Resident #1's oxygen concentrator (a machine that supplies concentrated oxygen) on 10/26/25 which resulted in the bottle being empty while the concentrator was in use and administering oxygen to the resident on 10/30/25. This failure could place residents at risk for dryness, irritation, nosebleeds, sore throats, thickened secretions, discomfort, and infection due to the dry oxygen.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurately documented for 1 of 5 residents (Resident #2) whose records were reviewed for resident identifiable records. - LVN A failed to document accurately when she documented a change of Resident #2's water used for her oxygen concentrator on 10/26/25 when she did not complete it. This failure could place residents at risk of having incomplete or inaccurate records and inadequate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review for 2 of 2 floors (1st floor and 2nd floor) reviewed for required postings. - On 10/30/25, the facility failed to ensure the Daily Associate Posting included the name of the facility and was displayed in a prominent place readily accessible to residents, staff and visitors by hanging it on the corner wall of the nursing station located on one end of the hall on the 1st and 2nd floor.- On 10/31/25, the facility failed to ensure the Daily Associate Posting on the 1st and 2nd floor included the resident census. This failure could affect residents, facility visitors, vendors, and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 3 residents (Resident #1) reviewed for pharmaceutical services. LVN C failed to remain in the room and monitor Resident #1's Family Member A administer medications to Resident #1. This failure could place residents at risk of not receiving the therapy needed.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for expired foods. The facility failed dispose of perishable foods after use in the walk-in fridge. This failure could place residents at risk for consuming hazardous expired food and developing foodborne illnesses who received food from the kitchen. Findings Included: Observation on 06/17/2025 at 10:48 AM revealed the following: *a bottle of Bay Leaves with use by date of 05/31/2025. * a package of Pork with use by date of 06/14/2025; *a package of Beef with use by date of 06/15/2025; *a package of Beef Tips with use by date of 06/10/2025; *a package of Brisket with use by date of 06/03/2025; and *a container of Chocolate Fudge Icing with use by date of 04/27/2025. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure 1 of 6 residents (Resident #1) reviewed for wound care received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing, in that: - The facility failed to identify a healed area to Resident #1's sacrum which included a scab and pink skin when Resident #1 admitted to the facility on [DATE]. Appropriate interventions were not implemented for Resident #1 and the area developed into a pressure ulcer within approximately 12 days of admission and eventually developed into a Stage IV pressure ulcer. - CNA B stated she did not reposition the resident frequently enough while working with Resident #1 upon her first few days admission. This failure placed residents with low skin integrity at risk for skin breakdown or failure of wounds to heal.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 1 resident (Resident #1) reviewed for infection. -The facility failed to ensure RN B performed hand hygiene during wound care for Resident #1. This failure could lead to the spread of infection to residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure for 1 of 12 residents (Resident #4) reviewed for resident assessments was assessed using the quarterly review instrument not less frequently than once every 3 months, in that: - Resident #4's EHR showed her quarterly MDS assessment was due for completion by 4/10/2024 but was not done by time of record review on 04/24/2024. This failure placed residents at risk of not receiving adequate care.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 6 residents (Resident #42) reviewed for pharmaceutical services. -The facility failed to administer the medication Esomeprazole (used to treat stomach acid related conditions) to Resident #8 on 04/21/2024, 04/22/2024 and 04/23/2024 as physician ordered. This failure could place residents receiving medication at risk of inadequate therapeutic outcomes and discomfort.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 7 % based on 2 errors out of 28 opportunities, which involved 2 of 6 residents (Resident #8, Resident #42) reviewed for medication errors. 1-LVN A failed to administer medications as physician ordered to Resident #8 as by not administering Esomeprazole Magnesium delayed release 40mg on 04/23/2024. The original order for Esomeprazole 40mg twice a day was dated 3/13/2024. The order status was on hold because the medication was out of stock on 04/23/2024. 2-LVN B failed to administer medications as ordered to Resident #42 as by administering Vitamin B12 with Folate instead of the physician order for Vitamin B12 without folate on 4/23/2024. [...]

Inspectors wroteBased on interview and record review the facility failed immediately consult with the resident's physician when there is a significant change in the resident's physical status for 1 (Resident #1) of 5 residents reviewed physician notification. Facility staff identified sacral wound on Resident #1 on 2/16/2024 and facility staff failed to perform and document a wound assessment, notify the physician, and obtain wound care orders until 4 days later 2/20/2024. An IJ was identified on 4/1/2024. The IJ template was provided to the facility on 4/2/2024 at 4:14pm. The Immediate jeopardy was removed on 4/4/2024 due to the facilities implemented actions that corrected the non-compliance. This failure could affect residents with impaired skin integrity and residents at risk for impaired skin integrity of developing life threatening infections, hospitalization, and worsening pressure ulcers.

Inspectors wroteBased on interview and record review the facility failed to ensure that a resident reviewed for pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for 1 (Resident #1) of 5 residents. 1. Facility staff identified sacral wound on Resident #1 on 2/16/2024 and facility staff failed to perform and document a wound assessment, notify the physician, and obtain wound care orders until 4 days later on 2/20/2024. Wound Care Physician assessed Resident #1 on 2/22/2024 and diagnosed Resident #1 with an unstageable (Due to Necroses) Sacrum Full Thickness pressure wound with a surface area of 129.72 cm. 2. Facility staff were performing dressing changes without a physician's order. An IJ was identified on 4/1/2024. The IJ template was provided to the facility on 4/2/2024 at 4:14pm. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice the comprehensive person-centered care plan and the resident's choices 1 of 5 residents (Resident #1) reviewed for quality of care. -The facility failed to enter orders for blood sugar monitoring for Resident #1, who had type 2 diabetes, upon admission and as a result the resident's blood sugar was not assessed for over 22 hrs. (01/17/24 at 02:50 PM to 01/18/24 at 01:11 PM) after admission. This failure could place residents at risk of delayed identification/treatment of acute health conditions and hospitalization. Findings Include: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for pharmacy services. - The facility failed to acquire and administer antibiotics antidiabetic medications timely to Resident #1 upon admission resulting in the resident's blood sugar level at 311 mg/dL. This failure could place residents at risk of not having their diseases treated, adverse events and hospitalization. Findings Included: Record review of Resident #1's Face Sheet dated 01/23/24 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: left hip fracture, overactive bladder, high cholesterol, difficulty swallowing and type 2 diabetes. Resident #1 transferred to facility after a hospital stay from 01/04/24 to 01/17/24. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurately documented for 1 of 5 residents (Resident #1) whose records were reviewed for resident identifiable records. - The facility failed to completely and accurately document administration of medication to Resident #1 by documenting administration of Insulin Lispro that was not in the facility and did not occur, This failure could place residents at risk of having incomplete or inaccurate records and inadequate care. Findings Included: Record review of Resident #1's Face Sheet dated 01/23/24 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: left hip fracture, overactive bladder, high cholesterol, difficulty swallowing and type 2 diabetes. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to promote healing, prevent infection and prevent ulcers from developing for 1 (Resident #2) of 11 residents reviewed for treatment of pressure ulcer. -The facility failed to provide treatment in a timely manner for Resident #2 who experienced a decrease in skin integrity to the sacral region that resulted in an unstageable wound to the sacral region diagnosed by the wound care doctor on 12/1/23. -The facility failed to do consistent weekly skin assessments on Resident #2. -Facility failed to change Resident #2's dressing to sacrum on 12/06/2023 as ordered by the wound care doctor. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a residents medical, nursing, mental and psychosocial needs for 2 (Resident #2, #4) of 11 residents reviewed for care plans. -The facility failed to have a comprehensive person-centered care plan for Residents #2 and Resident #4 to address indwelling Foley Catheters. This failure placed residents at risk for infections, injury, privacy, dignity, and decrease in quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident had the right to personal privacy including medical treatment for 2 (Resident #1 and Resident #4) of 11 reviewed for respect and dignity. -The facility failed to place Resident #1's Foley Cather bag inside of a privacy bag on 12/07/23. -The facility failed to place Resident #4's Foley Cather bag inside of a privacy bag on 12/09/23. This failure placed residents at risk of embarrassment and lower self-esteem.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection and prevention control program to help prevent the development and transmission of communicable disease and infections for 1 (Resident #1) of 11 residents reviewed for infection control. -Resident #1 indwelling Foley catheter bag was observed on the floor underneath Resident #1's bed on 12/07/23. This failure placed resident at risk for infections and decrease quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents received the necessary treatment and services, to promote healing and prevent infection for 1 of 3 residents (Resident #105) reviewed for pressure ulcer in that: -Facility staff failed to follow up with Wound Care Doctor's recommendation for left lateral forefoot/left medial foot wound care for Resident #105. This failure could place residents with wounds or who are at risk of developing wounds placing them at risk of infection, a decline in health, pain, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #105) of 3 residents reviewed for pain management. -The facility staff failed to stop a wound care treatment and provide Resident #105 with pain reduction care when the resident cried and yelled out from pain he experienced during the wound care treatment. This failure placed residents who received pain medications at risk for unmanaged pain during treatments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access for 1 of 6 residents (Resident #3) reviewed for medications in that: -The facility failed to ensure Resident #3 did not have medications clotrimazole cream 1% (a medicated antifungal skin cream. It treats certain kinds of skin fungal or yeast infections) and zinc oxide ointment (a medicated ointment that treats or prevents skin irritation like cuts, burns or diaper rash) in her room. This failure could affect residents and place them at risk for medication diversion, being administered the wrong medication, injury, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #105) reviewed for infection control, in that: -The facility failed to ensure LVN A performed hand hygiene when moving from a dirty to clean site, while performing Resident #105's wound care. This failure could place residents at risk for or infections.