Brooking Park

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective grievance process for residents and family members to be able to file a grievance verbally or anonymously. This deficient practice had the potential to affect all residents in the facility. The census was 81 with 21 residents in certified beds. Review of the facility's Resident Rights, dated 11/4/19, showed the following resident rights: Resident's right to voice grievances to the facility without discrimination or reprisal and without fear of discrimination or reprisal. Review of the facility's Grievance - Informal and Formal policy, dated 6/16/25 showed:-Residents have the right to file a grievance in writing or orally;-Grievance may be filed anonymously. Observation on 6/29/26 through 7/2/26, showed the facility posed three grievance signs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who required assistance with Activities of Daily Living (ADL, grooming, eating, oral hygiene) received necessary services when staff failed to provide feeding assistance to two residents (Resident #2 and Resident #10) during meals. Additionally, staff left a dinner tray in one resident's room without attempting to wake the resident up to eat and failed to check his/her mouth after eating for debris and provide oral hygiene to remove debris, as directed in his/her care plan (Resident #1). The sample was 10. The census was 53. Review of the facility's ADLs policy, reviewed/revised date 10/29/2025, showed:-Care and services will be provided for the following activities of daily living: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff provided adequate supervision and assistance for one resident (Resident #1) who required a mechanical lift (allow a person to be lifted and transferred with a minimum of physical effort) and two-person assistance for transfers when one staff transferred the resident without a mechanical lift. The sample was 10. The census was 53. Review of the facility's Safe Resident Handling/Transfer Policy, dated reviewed/revised 9/25/25, showed:-Policy explanation: all residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure acceptable nursing standards of practice when a resident was admitted from the hospital with a wound vacuum (wound vac, a medical device that provides light suction to a wound with high amounts of drainage to pull the excess drainage away from the skin) in place to his/her abdomen for treatment to an open surgical wound. The facility did not verify the wound vacuum treatment orders including wound vacuum dressing changes and needed supplies upon admission to the facility. As a result, the resident did not receive treatments as ordered by the hospital while at the facility. The resident discharged to the hospital on [DATE] for wound evaluation (Resident #1). The sample was 3. The census was 51. Review of the facility's Prevention and Treatment of Skin Breakdown and Other Skin Condition policy, dated 2017, showed:-Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Registered Nurse (RN) C completed and document physical and neurological assessments of Resident #1 after he/she was found unresponsive in his/her room by Certified Nursing Assistant (CNA) A. RN C went to the resident's room and found him/her sitting on the floor with his/her back leaning against his/her recliner. RN C failed to complete and document assessments of the resident after finding the resident on the floor and while waiting on emergency medical services (EMS) to arrive. Once EMS arrived, cardiopulmonary resuscitation (CPR, a lifesaving technique that's used in emergencies in which someone's breathing or heartbeat has stopped) was initiated. Three residents were sampled. The census was 62. Review of the facility Condition Change (Observing, Recording, and Reporting) policy revised on 2/2019, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff treated residents with dignity and respect when providing to perineal care (cleansing of genitalia and buttocks) to one resident (Resident #1). When providing peri care, staff failed to close the door to the resident's room, failed to close the window blinds failed to have a privacy curtain or other draping to prevent the exposure of the resident's genitalia and buttocks. The sample was seven. The census was 63 with 28 in certified beds. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/3/25, showed: -Severe cognitive impairment; -Requires assistance from staff with eating; -Dependent on staff assistance going from lying to sitting position; -Diagnoses included: [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective grievance process for residents and family members to voice grievances. The facility also failed to promptly resolve grievances for one resident (Resident #1). The sample was seven. The census was 63 with 28 in certified beds. Review of the facility's grievance policy, reviewed on 12/20/24, showed: -It is the policy of this facility that each resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of the staff and of other residents, and other concerns regarding their Long Term Care (LTC) facility stay; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who required assistance with activities of daily living (ADL, bathing, dressing and toileting) received the necessary services to maintain adequate personal hygiene. Staff failed to assist one resident with personal hygiene and failed to provide physician ordered showers. (Resident #1). The sample was seven. The census was 63 with 28 residents in certified beds. Review of the facility's Bathing policy, dated February 2019, showed: Policy: -To cleanse the skin on micro-organisms (small bacteria) thus preventing infections and preserving the integrity of the skin; -To provide comfort and relaxation, stimulate circulation, encourage passive and active range of motion (ROM) and improve self-esteem through appearance; -Bath days and the type of bath to be given will be assigned by the Charge Nurse. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy and the resident's care plan by ensuring two staff members safely assisted a resident who required a sit-to-stand mechanical lift for transfers (Resident #1). Staff failed to have two staff present at each transfer and failed to secure the safety belt around the resident's waist during a transfer. The sample size was seven. The census was 63 with 28 residents in certified beds. Review of the facility's Sara lift (a type of sit-to-stand mechanical lift) policy, dated September 2017, showed: -Purpose: To provide a safe transfer for all residents who are unable to be transferred by staff due to a physical condition; -Procedure: -Two nursing persons must be used for a Sara lift transfer; -Position sling around resident's back so it is approximately two inches above the waistline; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure one treatment cart remained locked when left unattended with medications on top of the cart. This practice could affect all residents residing in the facility. The census was 63 with 28 in certified beds. Review of the facility's Medication Administration-General Guidelines policy dated July 2021, showed all medication storage areas (carts, medication rooms, central supply) are locked at all times unless in use and under the direct observation of the medication nurse/aide. Observation on 3/19/25 at 11:00 A.M. to 11:17 A.M., showed the treatment cart on the Avalon unit unattended and unlocked. Multiple medications sat on top of the cart. Residents were seated and stood in the hallway near the cart. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident was served meals in a timely manner when staff served meals outside the timeframes designated by the facility (Resident #1). The sample was seven. The census was 63 with 28 in certified beds. Review of the facility's mealtimes showed: -Breakfast is served at 7:30 A.M. through 9:00 A.M.; -Lunch is served at 11:30 A.M. through 1:00 P.M.; -Dinner is served at 4:30 P.M. through 6:30 P.M. -Review on 3/19/25 at 10:05 A.M., of the meal service logbook, showed the space for each day to record the start and stop time for each meal service. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective grievance process for residents and family members to voice grievances and to promptly resolve grievances for one resident (Resident #1). The facility failed to follow-up on concerns expressed at Resident Council meetings. In addition, the facility failed to identify a Grievance Official responsible for overseeing grievances in their policy. The failure has the potential to affect all residents. The census was 52 with 25 in certified beds. Review of the facility's grievance policy, dated 2017, showed: -Preface: It is the policy of this facility that each resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents were served meals in a timely manner, which included two sampled residents (Resident #1 and Resident #2). The sample was eight. The census was 52 with 25 in certified beds. 1. Review of the facility's menus labeled Bistro 307 showed: -Breakfast is served at 7:30 A.M. through 9:00 A.M.; -Lunch is served at 11:30 A.M. through 1:00 P.M.; -Dinner is served at 4:30 P.M. through 6:30 P.M. 2. Review of Resident #1 's admission Minimum Data Set (MDS, a federally mandated assessment instrument competed by facility staff), dated 11/5/24, showed: -Severe cognitive impairment; -Requires moderate assistance from staff with eating; -Dependent on staff assistance going from lying to sitting position, -Diagnose included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who required assistance with activities of daily living (ADLs, bathing, dressing and toileting) received the necessary services to maintain adequate personal hygiene when staff did not provide showers to two residents (Resident #1 and Resident #2). The sample was eight. The census was 52 with 25 residents in certified beds. Review of the facility's Bathing policy, review date February 2019, showed; Policy: To cleanse the skin on micro-organisms (small bacteria) thus preventing infections and preserving the integrity of the skin; To provide comfort and relaxation, stimulate circulation, encourage passive and active range of motion (ROM) and improve self-esteem through appearance; Bath days and the type of bath to be given will be assigned by the Charge Nurse. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure one resident (Resident #1) who developed a newly acquired pressure ulcer (skin or soft tissue injury that develops with prolonged periods of pressure over specific areas of the body) had weekly skin assessments completed, according to the resident's care plan. Facility staff also failed to notify the physician of the new pressure wound and obtain new treatment orders in a timely manner. In addition, the facility staff failed to complete weekly skin assessments, according to facility policy, on one resident (Resident #2) who had a history of pressure ulcers. The sample was eight. The census was 52 with 25 residents in certified beds. Review of the facility's Prevention and Treatment of Skin Breakdown and Other Skin Conditions policy, dated 2017, showed: Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy and the resident's care plan and ensure two staff members assisted residents who required a sit-to-stand mechanical lift for transfers (Resident #2). The sample size was eight. The census was 52 with 25 residents in certified beds. Review of the facility's Sara lift (a type of sit-to-stand mechanical lift) policy, dated September, 2017, showed: Purpose: To provide a safe transfer for all residents who are unable to be transferred by staff due to a physical condition; Procedure: Two nursing persons must be used for a Sara lift transfer; Note: Nursing staff not using two nursing personnel for a Sara lift transfer will begin counseling process for failure to follow facility policy and procedures for safe transfer. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide one resident (Resident #1) with proper urinary catheter (tube that drains the urine from the bladder) care by failing to have catheter supplies readily available to ensure the resident's catheter was changed, and failed to obtain a urine specimen, according to physician orders, in a timely manner. The staff failed to place the resident's urinary catheter below the resident's bladder during a transfer, which put the resident at greater risk for infection. The sample was eight. The census was 52 with 25 in certified beds. Review of the facility's catheter policy, review date February 2019, showed: -Catheter Care should be given every shift and as needed; -Never lift bag above bladder level (source of infection); -Change drain bag and tubing every 30 days; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multi drug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS) for one resident with a urinary catheter (a tube that drains the bladder) for one resident (Resident #1). The facility failed to ensure staff used acceptable infection control practices with one resident when providing perineal care (peri-care, cleansing of the genitals) (Resident #1). [...]

Inspectors wroteBased on interview and record review, the facility failed to assess one of four sampled residents (Resident #1) for risk of entrapment from a bed rail and failed to ensure the bed rail did not pose a risk of entrapment when staff installed bed rails with a low air loss mattress. The resident was at risk for a serious adverse outcome when staff failed to assess the use of bed rails with the addition of a new low air loss mattress. On [DATE] at 9:40 P.M., staff found the resident on the floor with his/her head stuck between the rail and the mattress. The resident's buttocks were on the floor, his/her neck was stuck between the rail and the mattress, and his/her face was blue. The resident expired at the hospital. The census was 58. The Administrator was informed on [DATE] of an Immediate Jeopardy (IJ) past non-compliance, which occurred on [DATE]. [...]

Inspectors wroteBased on observation, interview, record review, and facility document and policy review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure: 1. open food items were labeled with a description of the food item and an open or expiration date; 2. food items were not stored beyond their use-by-dates and moldy onions were discarded; 3. dishware was allowed to airdry prior to use for meal service; 4. prepared foods were stored in a manner to prevent potential cross-contamination; and 5. the food preparation area and dietary equipment were maintained in a clean and sanitary manner, and the ceiling did not drip water onto the steam table used for meal service hot holding when it rained.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure enhanced barrier precautions (EBP) were implemented for 3 (Resident #17, #21, and #22) of 3 residents reviewed for EBP and failed to ensure respiratory equipment was stored in a manner to decrease risk of infection for 3 (Resident #22, #228, and #230) of 3 residents reviewed for respiratory care. The facility also failed to follow their infection control policy when staff failed to complete a two step and the annual one step of the employee tuberculosis (TB, a potentially serious infectious bacterial disease that mainly affects the lungs) screening tests in a timely manner for a total of seven employees. The census was 100 with 69 in certified beds.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure baseline care plans were completed within 48 hours of admission for 5 (Residents #178, #228, #230, #22, and #21) of 13 sampled residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a licensed practical nurse (LPN) verified the identity of the intended resident prior to obtaining a fingerstick blood sugar, which resulted in testing of the wrong resident. This affected 1 (Resident #17) of 2 residents observed during a finger stick blood sugar checks.

Inspectors wroteBased on observation, interview, record review, facility document review, and facility policy review, the facility failed to ensure a physician's order for the use of oxygen was in place for 1 (Resident #228) of 3 residents reviewed for respiratory care.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure medication was stored appropriately on the medication cart so that staff could administer the medication as ordered for 1 (Resident #8) of 13 sampled residents. The facility further failed to ensure ordered medication was available in the facility for administration for 1 (Resident #232) of 13 sampled residents.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure medications were securely stored for 2 (Resident #228 and Resident #21) of 13 in-house sampled residents observed with medications at their bedside.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the medical record for 1 (Resident #12) of 5 sampled residents reviewed for unnecessary medications accurately reflected the administration of medications. Specifically, staff interviews revealed oxycodone (a narcotic pain medication) that was removed from the facility's emergency medication supply was administered to Resident #12. However, Resident #12's administration record revealed no documentation indicating the medication was administered.

Inspectors wroteBased on observation, interview and record review, the facility failed to document and notify one resident's physician of a large area of redness on a resident's buttock which was discovered during a skin assessment (Resident #4). The sample size was 7. The census was 98 with 25 residents in certified beds. Review of the facility's Body Audit Policy and Procedure, undated, showed: -Policy: To be completed weekly for all residents to identify any new alterations in skin integrity; -Procedure: On designated day each resident is to have an assessment of their skin, obtain AMS Weekly Licensed Nurse Body Audit in the electronic medical record (EMR); -Provide privacy to resident; -The Nursing Assistant is to contact the Licensed Nurse for the skin inspection and pain assessment when the resident has been prepared for the skin inspection; [...]

Inspectors wroteBased on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to label, date and cover food, and discard expired food. The facility also failed to ensure a cup was removed from the flour and sugar bins and appropriately stored and failed to ensure kitchen equipment was kept clean during two of three days of observation. These deficient practices had the potential to affect all residents who consumed food from the facility kitchen. The sample size was 12. The census total was 51 with 23 in certified beds. 1. Observation on 2/21/23 at 9:40 A.M. and on 2/22/23 at 3:21 P.M., of the kitchen, showed the following: -Dry storage room: -A bag of mostaccioli noodles wrapped in plastic and without a date; -Three premium packages of popcorn with an expiration date 12/5/22; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 6 of 10 sampled staff hired within the past 12 months received their two-step tuberculin skin test. The census was 51 with 23 residents in certified beds. Review of the facility's Tuberculosis (TB) Exposure Control Plan policy, undated, showed: -Policy: It is the policy of this facility to institute an active TB Control Plan that includes identification of risk (to be included in the facility assessment information), early detection of latent TB infection, screening for infectious TB disease, follow-up where necessary, appropriate transfer and isolation of infectious TB, and treatment of persons with non-infectious TB; -All aspects of this facility's TB Control Plan will be contained in this document or is referred to by this document; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to perform a self-administration of medication assessment and obtain physician orders for one resident who was observed with medications left at his/her bedside (Resident #119). The sample size was 12. The census was 51 with 23 in certified beds. Review of the facility's Self Administration of Medication Policy, undated, showed: -Purpose: To allow for safe administration of medications by the resident in accordance to regulatory standards; -Policy statement: Self-control of prescription medication, a resident may be allowed only if approved in writing by the resident's physician and in accordance with facility standards; All medications shall be safely stored at proper temperature and shall be kept in a secured location behind at least one locked door or cabinet; -Procedure: -Assessment: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two residents (Resident #172 and Resident #16) had admission orders for their indwelling catheters (a sterile tube inserted into the bladder to drain urine). The sample was 12. The census was 51 with 23 in certified beds. Review of the facility's nursing services department policy and procedure, dated April/2020, showed: -Policy: admission orders will be transcribed in the medical record with accuracy; -Procedure: Upon admission, hospital orders will be accurately transcribed into the electronic medical record; Orders transcribed will include: Catheter orders for Foley (a sterile tube inserted to drain the bladder to drain urine) including size and balloon (a bulb at the end of the catheter that prevents the catheter from being dislodged) volume. 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to label and make the survey binder readily accessible to residents or visitors without having to ask for it. The census was 51 with 23 in certified beds. Observation on 2/21/23 at 1:00 P.M., 2/22/23 at 10:00 A.M. and 2/22/23 at 2:09 P.M., showed a white survey binder against the wall near the receptionist desk when entering the facility at the main entrance, with other white binders beside it. The binder was not labeled on the side of the binder for residents or visitors to know what it was. The binder was labeled on the front, but that part was not visible to residents or visitors without pulling the binder out from the location it was placed. During the Resident Counsel interview on 2/22/23 at 10 A.M., four residents who represent the resident population said they did not know where the survey binder was located. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written emergency transfer/discharge notices to residents and/or resident representatives for three of three residents sampled for emergency transfers (Residents #18, #77, and #78). In addition, the facility failed to notify a representative of the State Long-Term Care (LTC) Ombudsman of resident transfers and discharges. The census was 51 with 23 residents in certified beds. Review of the facility's Transfer and Discharge from the Facility policy, undated, showed: -If the facility cannot provide for the resident's needs, the resident may have to be transferred to another healthcare facility that can provide the services needed for the resident; -The resident and representative will receive timely notifications, adequate preparation, orientation and information to make the transfer as orderly and safe as possible. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policies for vital signs and change in condition by failing to immediately notify physicians when residents' blood pressures (BP) were low, thoroughly assess the residents and monitor the resident's until their BP returned to normal limits (120 (systolic/80(diastolic). One of eight sampled residents (Resident #17) had a low BP that exceeded the facility parameters of when to notify the physician. In addition, the facility failed to ensure the resident received the correct medications as listed on the After Visit Summary that accompanied the resident upon admission. That resident passed away at the facility two days after admission. Thirty residents from an expanded sample of past and present residents residing in certified beds were reviewed. [...]

Inspectors wroteBased on observation and interview, the facility failed to discard opened food items and maintain the cleanliness of the walk in freezer, walk in refrigerator, an oven, the stove top grill and the floor of the kitchen during three of four days of observation. This deficient practice affected all residents who ate at the facility. The census was 61 with 17 residents in certified beds. Observation on 7/9/19 at 8:33 A.M., of the main kitchen, showed: -One opened bag of what appeared to be frozen carrots, not labeled or dated, in the walk in freezer; -One opened bag of frozen biscuits, that had not been sealed after opening, inside of a box inside the walk in freezer; -Approximately four pepperoni slices were scattered on the floor of the walk in freezer; -One empty Styrofoam cup was in the corner of the walk in freezer floor; [...]