Brookhaven Nursing & Rehab

Inspectors wroteBased on interview and record review, the facility failed to provide care per standarda of practice when staff failed to correctly enter and follow the wound care specialist recommendations for the wound care treatment of one resident (Resident #1). The census was 64. Review of the facility's policy, Wound Care and Treatment, undated, showed the following:-It is the purpose of the facility is to prevent and treat all wounds;-There must be a specific order for the treatment;-The care plan should reflect the current status of the wound and appropriate goals and approaches.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect each resident's right to be treated with dignity and respect when one staff (Certified Medication Tech (CMT) F) spoke to one resident (Resident #1) disrespectfully in a raised voice and threatening manner. The facility census was 70. Review of the facility policy titled, Your Rights, As a Resident in a Long-Term Care Facility, undated, showed the following:-Residents will always be provided with the highest level of care and service, and if for any reason a resident feels that such needs are not being met by their facility staff, they are entitled to a variety of avenues in which to resolve their concerns;-Residents shall be treated with consideration, respect, and full recognition of dignity and individuality.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care per policy and standards of practice and failed have a system in place for timely administration of medications to residents when staff administered one resident's (Resident #2) medication late. The facility census was 70. Review of the facility's policy titled, Medication, Administration Guidelines, undated, showed the following:-It was the purpose of this facility that residents receive their medications on a timely basis and in accordance with established policies.1. Review of Resident #2's face sheet (brief resident profile) showed the following information:-admission date of 08/21/25;-Diagnoses included bipolar disorder (mental health condition with extreme mood swings between periods of mania), anxiety disorder, heart failure, hypertension (high blood pressure), and heart failure. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide pharmacy services to meet the needs of each resident when the facility failed to properly transcribe ordered medications, failed to clarify medication orders timely, and failed to administer medications as ordered for one resident (Resident #4) went he/she discharged from the hospital. The facility census was 70. Review of the facility's policy titled, Physician's Orders, undated, showed the following:-Physician's orders must be signed by the physician and dated when such order was signed;-Current lists of orders must be maintained in the clinical record of each resident to avoid confusion and errors;-Physician's orders must be reviewed and renewed;-Medication orders specify the type, route, dosage, frequency, and strength of the medication orders. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment as free of accident hazards as possible when the facility failed to complete a smoking assessment per policy and failed to care plan smoking for one resident (Resident #268) and when staff allowed three residents (Resident #27, #48, and #67), who were care planned to store smoking supplies at the nurses' station, to maintain smoking supplies on their person and in their room. The facility census was 75. Review of the facility's Smoking and Marijuana Use Policy, undated, showed the following: -All residents are advised that the facility is a supervised smoking facility; -There is a designated smoking area outside; -All smoking materials will be kept at the nurses' stations in an approved smoking container when not in use; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food prepared by the facility was palatable to the residents. The facility census was 75. Review of the facility policy, Food Temperatures, Nutrition and Dining Services Manual, dated May 2015, showed hot foods should be at least 120 degrees Fahrenheit (F) when served to the resident. 1. During an interview on 12/09/24, at 11:14 A.M., Resident #40 said the following: -He/she preferred to eat his/her meals in his/her room; -The food was cold probably at least half the time -He/she would like to have food that is warm, most of the time; -He/she said the eggs are always cold in the morning; -Eggs are his/her biggest complaint about the food, but it would be nice if it could all be warm. During interviews in the resident council meeting on 12/10/24, at 1:00 P.M., residents said the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep food safe from potential contamination or bacterial growth when staff placed clean dishes upside down on a tray, while still wet, which could potentially contaminate any food, served from those items. The facility census was 75. 1. Review of the facility's policy, Dish Machine, Nutrition and Dining Services Manual, dated May 2015, showed the following: -Pull the rack out of the machine to air dry; -Allow to air dry and stack in proper area. Record review of the 1999 Food Code, issued by the Food and Drug Administration, showed the following information: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food; -Items must be allowed to drain and to air-dry before being stacked or stored. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed establish and maintain an effect infection control program when the facility failed to screen all staff for tuberculosis (a contagious infection that usually attacks the lungs) at hire when the facility failed to complete the two-step tuberculin (TB) skin test for three staff member (Certified Nurse Aide (CNA) N, Licensed Practical Nurse (LPN) D, Dietary Aide (DA) M), out of 10 sampled staff members, per facility policy and standards of practice. Staff also failed maintain catheters (a tube that is inserted into the bladder to drain urine) in a manner to prevent the possible introduction bacteria in the system when the catheter bag and tubing for one resident (Resident #14) was on the ground. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete the required Preadmission Screening and Resident Review (PASARR - a two-level tool used to screen each resident in a nursing facility for a mental disorder or intellectual disability prior to admission) for one resident (Resident #5), prior to or upon admission to the facility, to ensure the resident received appropriate care and services, out of a selected sample of three residents. The facility census was 75. Review showed the facility did not provide a policy or procedure addressing completion of PASARR forms. 1. Review of Resident #5's face sheet showed the following information: -admission date of 06/04/10; -Diagnoses included paranoid schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly) and major depressive disorder. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's choice of code status (resident's wish to receive cardiopulmonary resuscitation (CPR - an emergency procedure for a person whose heart has stopped or who is no longer breathing) or do not resuscitate (DNR - does not wish to receive CPR)) was consistent throughout one resident's (Resident #55) medical records. The facility census was 75. Review showed no facility policy provided. 1. Review of Resident #55's face sheet showed the following: -admission date of [DATE]; -Code status of DNR; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice when the facility failed to follow consistently document and physician orders and failed to routinely document of notification of the physician and assessments in an elbow wound for one resident (Resident #60), out of 17 sampled residents. The facility census was 75. Review of the facility's policy titled Physician Orders, undated, showed the following information: -Current lists of orders must be maintained in the clinical record of each resident to avoid confusion and errors; -Orders must be reviewed and renewed; -Treatment orders must specify what is to be done, location, and frequency and duration of the treatment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers received services consistent with professional standards of practice when the facility failed to document regular full wound assessments for one resident (Resident #60) out of 17 sampled residents, who had a pressure ulcer to the right hip. The facility census was 75. Review of the facility's policy titled Resident Examination and Assessment, undated, showed the following information: -Examine and note the intactness, moisture, color, texture, and presence of bruises, pressure sores, redness, edema (swelling), and rashes of the resident's skin; -Document the following in the resident's chart the date and time the assessment was performed; name and title of individuals who performed the assessment; assessment data obtained during the assessment; [...]

Inspectors wroteBased on record review and interview, the facility failed to provide pharmacy services to meet the needs of each resident when staff failed to have ordered medications on hand for administration for two residents (Resident #49 and #13). The facility census was 75. Review of the facility policy titled Medication Administration, undated, showed medications are given to benefit a resident's health as ordered by the physician. 1. Review of Resident #49's face sheet (brief information sheet about the resident) showed the following: -admission date of 05/11/23; -Diagnoses included vitamin B12 deficiency (condition that develops when the body cannot make enough healthy red blood cells because it doesn't have enough vitamin B12). [...]

Inspectors wroteBased on record review and interview, the facility failed an medication error of less than 5 percent when staff made four medication errors out of 32 opportunities, affecting two residents (Resident #13 and #42) resulting in a 12.5 percent medication error rate The facility census was 75. Review of the facility policy, Medication Administration,' undated, showed the following: -Medications are given to benefit a resident's health as ordered by the physician; -Read the label three times before administering the medication. First when comparing the label with the medication sheet. Second when setting up the medication. Third when preparing to administer the medication to the resident; -Administer the medication; -Record the medication given on the medication sheet. 1. Review of Resident # 13's face sheet showed the following: -admission date of 02/02/21; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents were free of significant mediation errors when the facility failed to provide a meal service and/or a snack for one resident (Resident #42) after administering rapid acting insulin. The facility census was 75. Review of the facility's policy titled Medication Administration, undated, did not show any direction regarding insulin administration and/or fast acting insulin requirements. Review of the publication of the National Library of Medicine, titled Optimal Prandial Timing of Bolus Insulin in Diabetes Management, dated 11/2016, taking rapid acting insulin 15 to 20 minutes before a meal provides significant improvements in post-meal control and is recommended whenever possible. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's (Resident #1) right to be free from verbal and emotional abuse, by a staff member (Certified Nurse Aide (CNA) B) when staff yelled at and belittled the resident. The facility census was 70. Review of the facility's policy titled Handle with Care, Behavior Management System, Verbal Intervention Manual for Participants, latest publication 2012, showed the following: -Creating a universal perception of physical and psychological safety; -In order to act in the resident's best interest, staff need to be in control of their feelings and behavior; -Staff should interact with the resident during a crisis by allowing ventilation without becoming judgmental; considering the validity of the feeling if not the behavior, as it is impossible to tell another person how to feel; focus on one issue at a time; [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure all allegations of possible abuse were reported within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff witnessed and provided written statements regarding allegations verbal abuse of one resident (Resident #1) by a facility staff member. The facility census was 70. Review of the facility's policy abuse policy, undated, showed the following: -All allegations of abuse, neglect, exploitation, and mistreatment, injuries of unknown sources and misappropriation of resident property will be reported immediately, but no later than the following timeframes; -If abuse is alleged or there is serious bodily injury, the allegation must be reported within two hours after the allegation was made; [...]

Inspectors wroteBased on interview and record review, the facility failed to document completion of a full investigation of an allegation of employee to resident abuse towards one resident (Resident #1). The facility census was 70. Record review of the facility's Abuse Policy under the section, Investigation, undated, showed the following: -Designated facility personnel will begin the investigation immediately; -A root cause investigation and analysis will be completed; -The information gathered is given to administration; -The Administrator or designee will investigate the incident with the assistance of appropriate personnel; -The investigation will include who was involved; resident's involved statements; resident's roommate's statement; interviews with 3 to 4 residents receiving care from the alleged staff; interviews from 3 to 4 department staff (if possible); [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was stored, prepared, and distributed in a manner to prevent possibly contamination when staff failed to keep ice machine free of white substances, failed to dispose of outdated refrigerated foods, and when stored clean, wet dishes on a tray. This had the potential to affect all residents who consumed food from the facility kitchen. The facility census was 68. 1. Review of the 2013 Missouri Food Code showed food-contact surfaces of equipment and utensils shall be clean to sight and touch. Review of the facility's policy titled, Nutrition and Dining Services Manual, May 2015, showed wash the inside of the machine thoroughly with warm detergent solution, rinse with baking soda water, and dry monthly. Inside of the machine will be de-limed per facility guidelines monthly. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) at the initiation, reduction, or termination of Medicare Part A benefits for three sampled residents (Resident #67, Resident #123, and Resident #124) who remained in the facility upon discharge from Medicare Part A services. The facility census was 68. Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C -09-20), dated 01/09/09, showed the following information: -The Notice of Medicare Provider Non-Coverage (NOMNC - form CMS-10123) is issued when all covered Medicare services end for coverage reasons; [...]

Inspectors wroteBased on record review and interview, the facility failed to notify the resident and the resident's representative in writing of a transfer or discharge to the hospital for three residents (Resident #4, #16, and #17) out of a sample of eight residents. The facility census was 68. The Administrator and Assistant Director of Nursing (ADON) were notified on 05/01/23 of the Past Non-Compliance which had been ongoing and the ADON implemented an in-service for all nurses involved in sending residents to the hospital, provided transfer packets to all the nursing stations, began in-servicing of all nurses as they began their shifts, and began monitoring charts weekly to ensure no other incidents occur. The noncompliance was corrected on 05/02/23. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure all residents were free of significant medication errors when staff failed to administer medications as scheduled to three residents (Resident #13, #66, and #13) and when staff to prime an insulin pen and hold the insulin dose for six seconds at the site of administration as recommended by the manufacturer to ensure the resident received the full and correct dose of insulin for one resident (Resident #24). The facility had a census of 68. 1. Review of the facility policy, titled Medication, Administration Guidelines, undated, showed residents should receive their medications on a timely basis. 2. Review of Resident #13's face sheet (a brief resident profile) showed the following information: -admission date of 05/31/22; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious carrying contaminants when staff failed to use appropriate hand hygiene after performing incontinent care for one resident (Resident #4); failed to use appropriate hand hygiene before, during, and after performing glucometer (a machine used to check blood sugar) checks and failed to clean the glucometer after use for one resident (Resident #4); and when staff did not complete hand hygiene during medication pass and directly touched mediations for one resident (Resident #66). The facility census was 68. Review of the Centers for Disease Control and Prevention (CDC) website, updated 01/30/20, showed the following: [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a sanitary environment when the dietary and maintenance staff failed to ensure the fan located in the walk-in refrigerator and the vents on the ice machine were cleaned. The facility census was 68. 1. Review of the facility's policy titled Nutrition and Dining Services Manual, dated May 2015, showed the following: -The outside of the ice machine will be cleaned weekly; -Wash the outside with soft brush or cloth and dry; -Polish the outside with micro-shield or glass cleaner. Observations of the kitchen on 06/05/23, beginning at 9:10 A.M., and on 6/07/2023, at 3:00 P.M., showed the vents on each side of the ice machine had sticky substance and fuzzy lint. During an interview on 06/07/23, at 3:16 P.M., Dietary Aide A said dietary staff have a weekly deep clean and daily cleaning list for A.M. and P.M., staff. [...]

Inspectors wroteBased on interviews, record review, and observations, the facility failed to ensure all residents dignity was protected at all times when staff members failed to assist one resident (Resident #33), who attempted to disrobe in common area, in timely and failed to update the resident's care plan with new interventions related to the disrobing behavior. The facility census was 68. Review of the facility policy titled Resident Rights, undated, showed the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident. Resident rights are to be fully respected and adhered to. 1. Review of Resident #33 ' s face sheet showed the following: -admission date of 09/01/16; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide incontinent care for one resident (Resident #68) in a manner that prevented possible infection when staff failed to following proper hand washing during incontinent care and failed to provide catheter care per stands of practice. The facility census was 68. Review of the Centers for Disease Control and Prevention (CDC) website, updated 01/30/20, showed the following: -Hand hygiene (washing hands or using alcohol based hand rub) should be performed before putting on gloves; -Hand hygiene should be performed before moving from work on a soiled body site to a clean body site on the same resident; -Hand hygiene should be performed after body fluid exposure or assisting with toileting, performing would care, or performing a finger stick; -Hand hygiene should be performed after direct contact with a resident; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete side rail assessment, including a risk/benefit review and alternatives attempted prior to use, and failed to obtain informed consent for side rails for three residents (Resident #5, #57, and #65) in a selected sample of 20 residents. The facility's census was 75. Record review of the facility's Bedrails-Siderails-Grab Bars-Safety Rails policy, dated January 2017, showed the following: -Side Rail Assessment and Consent (Matrix (Matrix is electronic medical record system used by the facility) form) may be completed to determine if a side rail , bed rail, grab bar, or safety rail is the least restrictive device to restrain, resident' choice, and/or least restrictive device to treat a problem such as positioning in bed. 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the residents' bathroom exhaust ventilation systems in proper working condition when 16 residents' bathrooms did not have functioning exhaust vents. The facility had census was 75. 1. Observations on 1/30/20, beginning at 8:30 A.M., showed the exhaust ventilation system in the following resident bathrooms did not have functioning exhaust ventilation system when tested: -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure privacy for one resident (Resident #330) in a selected sample of 20 residents. The facility's census was 75. Record review of the facility's admission Packet of Resident's Rights included the following information: -Each resident shall be treated with consideration, respect a full recognition of his/her dignity and individuality, including privacy in treatment and care of his/her personal needs. All persons, other than Division of Health Standards and Licensure or Department of Mental Health staff, as appropriate, shall be excluded from observing the Resident during any time of examination, treatment or care unless consent has been given by the Resident. 1. Record review of Resident #330's face sheet (a document that gives a resident's information at a quick glance) showed the following information: [...]

Inspectors wroteBased on interview and record review, the facility failed to complete an investigation of an allegation of misappropriation of resident property for two residents (Resident #2 and Resident #14) in a selected sample of 20 residents. The facility's census was 75. Record review of the facility's Abuse Policy, revised 11/28/16 related to the facility investigative documentation showed the following: -A specific description of the incident; -Relevant information/documentation from the resident's medical record (i.e., face sheet, nurse's notes, MDS, care plan, physician notes and discharge information). -Names, addresses, home telephone numbers, date of birth , social security numbers and positions of staff involved in the incident. -Written statements by all persons with knowledge of the incident. Statements must be signed, dated and give specific details. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician of a new wound and obtain a physician's order for wound care. Staff applied wound treatments without a physician's order, failed to apply a treatment as ordered, and failed to use proper hand hygiene according to facility policy, during and after wound care for one resident (Resident #57) out of a sample of 20. The facility census was 75. Record review of the facility's (undated) Physician's Order Policy, showed for treatments orders: Specify what is to be done, location and frequency, and duration of the treatment. Record review of the facility's Wound Care and Treatment Policy, dated March 2015, showed the following: -Universal precautions and strict hand washing procedure for all wound care and/or patient contact; -It is the purpose of this facility to treat all wounds; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician order for continous oxygen, and failed to identify, develop and implement interventions for Oxygen use for one resident (Resident #58) in a selected sample of 20 residents. The facility's census was 75. Record review of the facility's policy, dated March 2015, titled Oxygen Administration, showed the following information: -At regular intervals, check and clean oxygen equipment, masks, tubing and cannulas; -Place cannula tubing in plastic bag attached to concentrator when tubing is not in use; -Check resident's respiration and observe at regular intervals to assess need for further oxygen therapy after oxygen has been discontinued. 1. Record review of Resident #58 face sheet (a document that gives a patient's information at a quick glance) showed the following: -admission date of 12/18/19; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff administered medications with an error rate of less than 5%. Facility staff made two errors out of 26 opportunities, resulting in an error rate of 7.69%, which affected two residents (Resident #24 and #52). The facility census was 75. Record review of the Humalog (name brand of lispro-a fast acting insulin) FlexPen (device used to administer the insulin) manufacturer's insert, dated November 2019, showed the following information: -Humalog insulin should be administered 15 minutes before a meal or immediately after a meal; -Hypoglycemia (low blood sugar) is the most common adverse reaction to insulin therapy and may be life-threatening. Symptoms may be different for each person and may change from time to time. Severe hypoglycemia can cause seizures and may be life threatening or cause death. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors when staff failed to prime an insulin pen and administer the insulin (medication used to lower blood sugar levels) as directed by the manufacturer for one resident (Resident #52), during a random medication pass observation. The facility census was 75. Record review of the Humalog (name brand of lispro-a fast acting insulin) FlexPen (device used to administer the insulin) manufacturer's insert, dated November 2019, included the following information: -Prime the pen before each injection: Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly; If you do not prime before each injection, you may give too much or too little insulin; [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure temperature-sensitive medications were stored at the appropriate temperatures for two refrigerators in one of two medication rooms. The facility census was 75. Record review of the facility's Storage of Medications Policy, dated March 2015, showed the following: -Biologicals or medications must be kept in a separate, securely fastened refrigerator, at or near the nurse's station within a locked medication room; -Drugs stored in the refrigerator must be stored between 36 and 46 degrees Fahrenheit. 1. Record review of the January 2020 Refrigerator Temperature Log for refrigerator 1 (the top refrigerator), located in the CDE medication room, showed the following: -Staff did not document refrigerator temperatures for 21 days (1/2/20, 1/4/20, 1/7/20-1/16/20, 1/18/20-1/21/20, 1/23/20, 1/24/20, 1/27/20, 1/28/20, and 1/30/20; [...]

Inspectors wroteBased on interview, and record review, the facility staff failed to employ a qualified dietary manager for food and nutrition services with accredited education in food service management. The facility census was 75. 1. Record review of the facility's dietary staffing schedule showed the facility employed a Dietary Manager (DM). An interview on 1/31/20, at 10:25 A.M., showed the following: -The DM said he worked at the facility for two years as a Certified Nursing Assistant (CNA). -Approximately two months ago, he started working as the DM but he had no experience working in food management in long term care. -The facility gave him a book to study and to use for the Dietary Mangers' certification test. -He was not a Certified Dietary Manager. He had one year to take the certification test. [...]