Brookridge Cove Rehabilitation and Care Center

Inspectors wroteBased on facility document review, interviews, record review, and facility policy review, it was determined that the facility failed to ensure sufficient staffing to meet the residents' needs as evidenced by not following the facility assessment staffing guidelines for 15 of 15 shifts reviewed from 01/04/2025 day shift through 03/06/2025 night shift.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure that the dish washing machine vent hood was free of rust; the pest trap was free of rust and dirt; two of three ice machines were maintained in a clean and sanitary condition in one of two kitchens; expired food item was promptly removed / discarded on or before the expiration or use by date, and dietary staff washed their hands before handling clean equipment or food items for two of two meals observed. Based on observation, interview, and facility policy review, the facility failed to ensure a pest trap was free of rust and dirt and kept away from meal preparation areas; two of three ice machines were maintained in a clean and sanitary condition in one of two kitchens; [...]

Inspectors wroteBased on record review, interviews, and social media observations, the facility failed to ensure a resident's photograph was not posted on social media without permission and was not visible to the public or other residents, to maintain dignity and privacy for one (Resident #70) of one resident observed.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, it was determined the facility failed to ensure that staff performed proper hand hygiene when providing incontinent care for two (Resident #56 and Resident #92) of two residents observed and followed Enhanced Barrier Precautions (EBP) for one (Resident #92) of one resident observed for EBP.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, and homelike environment as evidenced by not ensuring safe wall mounted railings for safety and convenience.

Inspectors wroteBased on observation and interview, the facility failed to ensure 1 of 1 kitchen was in sanitary condition.

Inspectors wroteBased on observation and interview, the facility failed to ensure Resident ' s bedding was clean and in place for 1 (Resident #1) of 1 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an accident/hazard free environment was provided for smokers requiring a smoking apron.

Inspectors wroteBased on observation, and interview, the facility failed to ensure staff washed their hands between dirty and clean tasks and before handling clean dishes or food items to prevent the potential for food borne illness for residents who received meals from 1 of 2 kitchens; failed to ensure dairy products were maintained at or below a temperature of 41 degrees Fahrenheit; failed to ensure expired food items were promptly removed/discarded by the expiration or use by dates to prevent the potential for food borne illness for residents who received meals from 2 of 2 kitchens. These failed practices had the potential to affect 85 residents who received meals from the Main Kitchen and 11 residents who received meals from the Cottage (total census:107), as documented on the list provided by Dietary Supervisor on 02/14/23 at 2:27 PM.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents received an individual Quarterly Financial Record Statement for 2 (Residents #58 and #74) of 13 (Residents #5, #10, #14, #17, #31, #46, #53, #55, #58, #65, #74, #81 and #83) sampled residents who had Trust Funds managed by the facility. This failed practice had the potential to affect 44 residents who had Trust Funds managed by the facility as documented on the Trust Transaction Current Account Balance received from the Business Office Manager (BOM) on 02/15/23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure contact information for the State Long-Term Care Ombudsman, the Office of Long Term Care (OLTC) Complaint Department were posted and readily accessible to all 11 residents who resided in the Cottage at the facility.

Inspectors wroteBased on interview, and record review, the facility failed to ensure mail was provided on Saturdays to honor resident rights and prevent potential delays in receipt of mail. This failed practice had the potential to affect all 107 residents who resided in the facility as documented on the Resident Census and Conditions of Residents provided by the Administrator on 02/14/23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the confidentiality of resident records were kept private by locking the computer screens when not in use. This failed practice had the potential to affect 93 residents who received medication from the medication carts in the facility's main building as documented on a list provided by the Registered Nurse (RN) Consultant on 02/16/23 at 4:03 PM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure bathing services were regularly provided and chin hairs were removed to maintain good hygiene for 1 (Resident #93) of 30 (Residents #5, #10, #14, #16, #17, #18, #31, #35, #37, #42, #44, #50, #58, #59, #63, #65 #66, #70, #71, #83, #88, #93, #96, #96, #97, #99, #100, #104, #157, #457 and #507 sampled residents who required assistance with bathing and/or grooming. This failed practice had the potential to affect 74 residents who required assistance from staff for bathing/showers according to a list provided by the Registered Nurse (RN) Nursing Consultant on 02/16/23 at 4:03 pm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the metal bolts securing toilet seats were cut to a safe length to prevent potential accidents and injury to residents on the Secure Unit for 1 (Resident #96) of 7 (Residents #18, #65, #66, #88, #96, #99 and #100) sampled residents who were able to stand and move on their own. The failed practice had the potential to affect 18 residents on the Secure Unit who were able to stand and move on their own as documented on a list provided by the Registered Nurse (RN) Consultant on 02/17/23.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a residents Continuous Positive Airway Pressure (CPAP) mask was properly stored when not in use to prevent potential contamination that could result in respiratory infection and failed to ensure a malfunctioning CPAP machine was reported and replaced in a timely manner consistent with professional standards of practice and to prevent possible respiratory complications for 1 (Resident #34) of 2 (Residents #34 and #507) sampled residents who had Physician Orders for CPAP.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure meals were prepared and served in accordance with the planned, written menu to meet the nutritional needs of the residents for 1of 2 meals observed. This failed practice had the potential to affect 6 residents who received pureed diets and 32 residents who received mechanical soft diets, 59 residents who received regular diets, in the Main Building and the residents on pureed diets were to receive a #8 scoop of pureed 4 Layer Delight according to a list provided by Dietary Supervisor on 02/14/23 at 2:27 PM.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for 1 (Resident #88) of 18 (Residents #2, #17, #21, #26, #31, #34, #35, #42, #53, #55, #74, #88, #93, #94, #96, #97, #257 and #507) sampled residents whose MDS was reviewed. This failed practice had the potential to affect 107 residents who resided in the facility as documented on the Daily Census provided by the Administrator on 02/13/23.

Inspectors wroteBased on observation, record review, and interview, the facility failed to reassess the effectiveness of interventions, and review and revise the Care Plan for 1 (Resident #74) of 4 (Residents #37, #59, #63 and #74) sampled residents whose Care Plans were reviewed. This failed practice had the potential to affect all 4 residents in the Cottage who received Diabetic Nail Care as documented on the Diagnosis Report provided by the Administrator on 02/15/23 at 11:28 AM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Diabetic Toenail Care was provided for 1 (Resident #74) of 4 (Residents #37, #59, #63 and #74) sampled residents who were dependent on assistance with Diabetic Nail Care as documented on the Diagnosis Report provided by the facility Administrator on 02/15/23 at 11:28 AM.

Inspectors wroteBased on interview, and record review, the facility failed to ensure all staff received complete primary COVID-19 vaccinations, had an approved or pending medical or religious exemption, or a temporary delay per the Center for Disease Control (CDC) per the Centers for Medicare and Medicaid Services (CMS) COVID-19 Health Care Staff Vaccination Regulations Quality Service and Oversight (QSO) and staff vaccination tracking records were updated timely.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the residents residing in the Cottage at the facility were allowed to hold Resident Council meetings without staff present.