Brooke Knoll Village

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure enhanced barrier precautions were implemented per facility policy and ensure appropriate professional standards for infection prevention were implemented for 3 of 27 residents reviewed for infection control (Residents 105, 77, and 1).

Inspectors wroteBased on record review and interview, the facility failed to accurately code a Minimum Data Set (MDS) (a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) for 1 of 6 residents reviewed for MDS accuracy (Resident 11).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure baseline care plans were implemented for 1 of 5 residents reviewed for baseline care plans (Residents 105).

Inspectors wroteBased on observations, record review, and interview, the facility failed to correctly administer insulin for 1 of 1 resident observed for insulin administration (Resident 63).

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure activities of daily living (ADLs) nail care was provided for residents who were dependent on staff for person hygiene for 3 of 4 residents reviewed for nail care (Residents 51, 61, and 1).

Inspectors wroteBased on observations and interviews, the facility failed to label over the counter medications and failed to date medications when opened for 3 of 5 medication carts reviewed and 1 of 1 medication room (Residents 103, 7, 24, and 18).

Inspectors wroteBased on record review and interview, the facility failed to ensure documentation in a resident's medical record was accurate for 1 of 18 resident records reviewed (Resident 4).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure tube feedings were administered per physician orders for a resident with known weight loss and who received all their nutrition by Gastric Tube (G tube) for 1 of 1 residents reviewed for tube feeding (Resident B).

Inspectors wroteBased on observations and interviews, the facility failed to prevent the potential for infection when they failed to change a used suction canister for over a week for 1 of 3 residents reviewed for infection control practices (Resident B).

Inspectors wroteBased on observations and interviews, the facility failed to ensure controlled substances were appropriately stored in a medication cart for 1 of 2 narcotic count observations.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure residents had the right to privacy and dignity when staff failed to knock and announce themselves before entering the residents' room for 3 of 3 residents reviewed for dignity (Resident 25, 34, and 46), and for 1 of 1 resident council meeting (Residents 9, 20, 48, 11, and 43).

Inspectors wroteBased on observation and interview, the facility failed to date medications when opened and label over the counter medications for 3 of 6 medication carts reviewed (Residents 34, 47, 5, 64, 49, 11, 44, and 59).

Inspectors wroteA. Based on observations, interviews, and record reviews, the facility failed to ensure appropriate infection control measures were used during the administration of a nasal spray for a resident for 1 of 1 observation of a nasal spray administration (Resident 13). B. Based on observations, interviews, and record reviews, the facility failed to ensure consistent and effective infection control practices related to enhanced barrier precautions (EBP) to ensure staff and visitors were aware of who required EBP and that personal protective equipment (PPE) was readily accessible for 6 of 6 residents reviewed for EBP (Residents 44, 34, 41, 71, 15, and 46).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident had the right to chose when he received routine lab draws that honored his preference not to be woken up too early for 1 of 1 residents reviewed for choices.

Inspectors wroteBased on record review and interviews, the facility failed to initiate a new PASARR (Preadmission Screening and Resident Review)screening after a new mental health diagnosis was added to the diagnosis listing for 1 of 1 resident reviewed for PASARR (Resident 3).

Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive discharge plan was in place and implemented for 1 of 2 closed record reviewed (Resident 80).

Inspectors wroteBased on observation, record review, and interview, the facility failed to prevent the potential for accidents related to medications at bedside for 2 of 4 residents reviewed for accidents (Residents 60 and 33).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents with significant past trauma and/or post-traumic stress disorder (PTSD) received personalized care to address and avoid triggers for 2 of 2 residents reviewed for trauma informed care (Residents 25 and 65).

Inspectors wroteBased on record review and interview, the facility failed to follow up with pharmacy recommendations in a timely manner for 1 of 5 residents reviewed (Resident 69).

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's wheelchair wheels were engaged into the facility van wheelchair-locks properly for 1 of 3 residents reviewed for accidents (Resident B). The deficient practice was corrected on 2/22/24, prior to the start of the survey, and was therefore Past Noncompliance.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call lights were placed within reach for 4 of 4 residents randomly observed for call light placement (Residents 13, 31, 52 and 71).

Inspectors wroteBased on observation and interview, the facility failed to ensure that expired medications were replaced and failed to ensure a refrigerated medication was stored in the refrigerator for 5 of 6 residents reviewed for medication storage (Residents 5, 38, 58, 68, and 243).

Inspectors wroteBased on observation and interview, the facility failed to accurately code the MDS (Minimum Data Set) for 1 of 2 residents reviewed for PASARR (Pre-Assessment Screening and Resident Review) for 1 of 2 residents reviewed for accuracy (Resident 39).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's toenails were cut to prevent discomfort for 1 of 1 resident reviewed for activities of daily living care (Resident 15).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's equipment was maintained and free from the potential for accidents for 1 of 5 residents reviewed for accidents (Resident 33), and failed to ensure medications were not left at bedside for 1 of 5 residents reviewed for accidents (Resident 21).

Inspectors wroteBased on observation, record review, and interview, the facility failed to date feeding and water bags for 1 of 2 residents reviewed for feeding tubes (Resident 78).

Inspectors wroteBased on observation and interview, the facility failed to exchange oxygen equipment for a resident who received oxygen therapy for 1 of 4 residents (Resident 37).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure culturally appropriate and person-centered services, routine/preferences, and activities were available and/or implemented for a resident who spoke a different language for 1 of 1 residents reviewed for culturally competent care (Resident 71).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hand washing was completed according to policy for 2 of 4 residents (Residents 1 and 51).