Brookshire Post Acute

Inspectors wroteBased on interviews and record review, the facility failed to take steps to protect one (#1) of three residents from physical abuse out of six sample residents reviewed for abuse. Specifically, the facility failed to protect Resident #1 from physical abuse by Resident #2 on 10/15/25.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for one (#10) of five residents out of 10 sample residents. Resident #1, age less than 65, required total assistance with bathing, was non-verbal and was unable to move his arms and legs. On 10/10/25 at 3:55 p.m. certified nurse aide (CNA) #1 requested a nurse to look at Resident #1's skin in the Summit shower room. CNA #1 stated she was using a washcloth and the resident's skin flaked off. The washcloth was noted to be light brown in color and peeled skin was observed on the shower floor. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance and performance improvement (QAPI) program committee failed to identify and address concerns related to accidents and safety of residents in which the facility failed to ensure hot water temperatures did not exceed safe temperature ranges that rose to the level of immediate jeopardy and created a situation that a serious adverse outcome was likely.

Inspectors wroteBased on observations and interviews the facility failed to store, prepare, distribute and serve food in a sanitary manner in the kitchen. Specifically, the facility failed to: -Ensure raw animal food was separated from ready to eat food; -Ensure expired food was discarded; and, -Ensure food was labeled and dated appropriately.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a prompt resolution was provided to residents involved in group grievances. Specifically, the facility failed to provide a prompt and effective resolution for resident council members who repeatedly voiced concerns over staff conduct.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure three (#32, #60, #50) of five residents reviewed for activities out of 30 sample residents received an ongoing program of activities designed to meet the needs and interests, and promote physical, medical and psychosocial well-being. Specifically, the facility failed to offer and provide a personalized activity program for Resident #32, Resident #60 and Resident #50.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure the laundry room was free from multiple environmental concerns.

Inspectors wroteBased on record review and interviews, the facility failed to develop, implement and maintain an effective training program for staff based on the facility assessment and resident population for four of five certified nurse aides (CNA) reviewed. Specifically, the facility failed to: -Ensure CNA #5 and CNA #6 received training in abuse, dementia management, behavioral health management, infection control, communication, quality assurance and quality improvement (QAPI), compliance and ethics, and resident rights; and, -Ensure CNA #3 and CNA #4 received at least 12 hours of annual in-service training.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#47) of five residents out of 30 sample residents had the right to be informed of and participate in their treatment,the right to be informed, in advance, of the care to be furnished and the type of care giver or professional that would furnish care, the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. Specifically, the facility failed to obtain a consent from Resident #47 or their legal representative for the use of an antipsychotic medication before its administration.

Inspectors wroteBased on record review and interviews, the facility failed to inform one (#60) of three residents reviewed for beneficiary notices and appeal rights out of 30 sample residents of changes in their services covered by Medicare in a timely manner. Specifically, the facility failed to provide written notification of a Medicare Non-Coverage letter to the resident's representative that Medicare-covered services were ending for Resident #60 in a timely manner.

Inspectors wroteBased on record review and interviews, the facility failed to develop a comprehensive care plan for two (#46 and #9) of six residents out of 30 sample residents for services to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to: -Ensure a comprehensive care plan was developed to address Resident #46's use of an anticoagulant medication; and, -Ensure a comprehensive care plan was developed to address Resident #9's dental needs.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#113) of three residents reviewed for assistance with activities of daily living (ADL) out of 30 sample residents received appropriate treatment and services to maintain or improve his or her abilities. Specifically, the facility failed to ensure Resident #113 received assistance with showers in accordance with her physician orders.

Inspectors wroteBased on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for two of five certified nurse aides (CNA) reviewed. Specifically, the facility did not complete a performance review for CNA #3 and CNA #4.

Inspectors wroteBased on observation,record review and interviews, the facility failed to assist residents in obtaining routine or emergency dental services, as needed for one (#14) of two residents reviewed for dental services out of 30 sample residents. Specifically, the facility failed to ensure dental services were offered to Resident #14.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that the medical record was complete and accurate in keeping with accepted standards of practice for one (#63) of four residents reviewed for medical record accuracy out of 30 sample residents. Specifically, the facility failed to document Resident #63's toileting in an accurate and easy to understand manner.

Inspectors wroteBased on observations and interviews the facility failed to maintain a clean, comfortable and homelike environment for the residents on two of the two resident hallways and the secured unit. Specifically, the facility failed to ensure residents' rooms, bathrooms and shower rooms were odor free and received necessary repairs.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure proper storage of medications for the medication storage room and one of two medication storage carts. Specifically, the facility failed to: -Discard medication on the medication cart that had been discontinued; and, -Discard medications that have expired.

Inspectors wroteBased on record review and interviews the facility failed to have a system for identifying deviations in performance and adverse events, and develop and implement appropriate quality assurance and performance improvement (QA/QAPI) plans of action to correct identified quality deficiencies. Specifically, the QAPI program committee failed to identify failures within their performance improvement plans for repeat deficiencies cited and make the necessary changes to ensure the plan was effective.

Inspectors wroteBased on observations and interviews, the facility failed to ensure one (#18) out of 25 sample residents had the right to a dignified existence. Specifically, the facility failed to ensure facility staff respected Resident #18's right to refuse a shower and provide him dignity after a shower by ensuring he was not exposed to other residents on the unit by wrapping him in a see-through sheet.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#27) of five residents reviewed for abuse out of 25 sample residents were kept free from abuse. Specifically, the facility failed to: -Investigate and implement measures to protect Resident #27 from Resident #46 on 12/5/23; and, -Ensure Resident #27 was kept free from physical abuse by Resident #46 on 12/5/23 and 12/21/23.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure one (#18) out of 25 sample residents were free from involuntary seclusion. Specifically, the facility failed to ensure Resident #18, who resided on the secured unit, had the required assessments and resident representative consent to justify such restrictions.

Inspectors wroteBased on record review and interviews, the facility failed to report abuse to State Survey and Certification agency in accordance with State law for one (#27) of six residents reviewed for abuse out of 25 sample residents. Specifically, the facility failed to report incidents of alleged abuse involving Resident #27 to the State Agency.

Inspectors wroteBased on record review and interviews, the facility failed to thoroughly investigate allegations of abuse involving one (#27) of six residents reviewed for abuse out of 25 sample residents. Specifically, the facility failed to conduct an investigation of bruising and scratches (injuries of unknown origin) to Resident #27. Cross-reference F609 the facility failed to injuries of unknown origin to Resident #27 were reported to the State Agency.

Inspectors wroteBased on record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain vision abilities for one (#50) resident of two residents reviewed for ancillary services out of 25 sample residents. Specifically, the facility failed to ensure Resident #50 was provided with an eye exam.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#11 and #50) of two residents who entered the facility with limited mobility and range of motion received appropriate services and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrated as unavoidable out of 25 sample residents. Specifically, the facility failed to ensure: -Resident #11 received restorative services to prevent potential worsening of functional ability; and, -Ensure Resident #50 was provided with restorative services to help with mobility.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#13 and #53) of three out of 25 sample residents received adequate supervision to prevent accidents. Specifically failed to: -Implement effective fall interventions for Resident #13 and Resident #53; -Update care plan with new interventions for Resident #13 and Resident #53; and, -Implement current fall interventions and supervision requirements for Resident #13 and Resident #53.

Inspectors wroteBased on record review, observation and interviews, the facility failed to ensure residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain and maintain the highest practicable mental and psychosocial wellbeing for one (#50) out of 25 sample residents. Specifically, the facility failed to provide an ongoing assessment as to whether care approaches were meeting the emotional and psychosocial needs for Resident #50.

Inspectors wroteBased on observation, record reviews and interviews, the facility failed to ensure one (#55) of six out of 25 sample residents were as free from unnecessary drugs as possible. Specifically, the facility failed to ensure Resident #55's drug regimen prescribed was free from an excessive amount of Acetaminophen which exceeded the recommended daily consumption.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#3) of two residents reviewed for abuse out of seven sample residents was free from resident-to-resident abuse. Residents #3 and #6, both severely cognitively impaired, were roommates as of 7/18/23, the date of Resident #3's admission to the facility. Resident #6 had a documented history of resident-to-resident physical and verbal aggression toward staff and other residents, including on 7/25/23 with Resident#3 for talking in his sleep. Despite staff knowing Resident #6's history of resident-to-resident altercations, including against Resident #3 on 7/25/23, staff failed to monitor and develop effective interventions to protect Resident #3 from Resident #6's further abuse. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide the necessary treatment and services to prevent pressure injuries from occurring and worsening for one (#1) of three out of seven sample residents. Specifically, a staff interview revealed that on 10/5/23, she notified a nurse that Resident #1 had a small open area on her coccyx. The facility failed to ensure the resident's skin breakdown was comprehensively assessed and had a physician-ordered treatment in place until 10/9/23, four days after the pressure injury was identified. The wound physician's assessment on 10/9/23 revealed an unstageable pressure injury to the coccyx with obscured full-thickness skin and tissue loss. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure one (#1) of three out of seven residents with limited range of motion received appropriate treatment and services. Specifically, the facility failed to properly assess the resident's contracture and ensure the comprehensive care plan identified the contracture, and interventions were put into place to prevent the worsening of Resident #1's left elbow and left hand contracture. Although there were no measurements, staff and resident representative interviews revealed the resident's contracture had worsened.

Inspectors wroteBased on record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency in accordance with state law for two (#1 and #4) of four residents reviewed for abuse out of seven sample residents. Specifically, the facility failed to report incidents of alleged abuse to the State Agency involving Resident #1 and Resident #4.

Inspectors wroteBased on record review and staff interviews, the facility failed to investigate an allegation of abuse for two (#1 and #4) of three residents reviewed for abuse out of seven sample residents. Specifically, the facility failed to thoroughly investigate the following allegations of abuse for Resident #4 and Resident #1.

Inspectors wroteBased on observation, record review and interviews the facility failed to ensure one (#3) out of seven sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to ensure blood pressure medication was consistently ordered for Resident #3 by the nursing staff.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to create an environment that protected eight of 21 residents reviewed (#20, #32, #42, #12, #33, #45, #37 and #55) from abuse. RESIDENT TO RESIDENT SEXUAL ABUSE Resident #20, with moderate cognitive loss, exhibited inappropriate sexual behavior toward three residents (#42, #12, and #32), all of whom were severely cognitively impaired. Resident #42 was touched inappropriately on her breast on 7/14/22, Resident #12 was touched inappropriately on her breast on 8/29/22, and Resident #32 was touched inappropriately on her breast on 9/26/22, during the survey. [...]

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement appropriate quality assurance and performance improvement (QAPI) plans of action to correct identified quality deficiencies, potentially affecting all the residents in the facility. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify concerns and or implement effective action plans to mitigate the repetition facility failures in abuse and behavioral health.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure that five (#32, #8, #11, #4, and #60) of 22 out of 33 sample residents were free from involuntary seclusion and were receiving the least restrictive approach for their needs. Specifically, the facility failed to ensure Residents #32, #8, #11, #4, and #60, residing on the secure locked unit, had the required documentation to justify such restrictions including documentation such as doctor orders, resident representative consents, and secure unit evaluations were not obtained. I. Facility policy The Secure Unit Placement policy, dated 11/4/13, was provided by the nursing home administrator on 9/29/22 at 10:52 a.m. It read in pertinent part, The Admissions Coordinator, Social Services or designees shall assess the potential resident to include: [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for five (#60, #4, #20, #55 and #37) of 12 out of 33 sample residents. Specifically, the facility failed to consistently provide person-centered approaches to Resident #60, #4, #20, #55 and #37 who had diagnoses of dementia, involved in resident to resident altercations on the secured unit (cross-reference F600 for abuse).

Inspectors wroteBased on observations, record review and interviews, the facility failed to develop and implement a COVID-19 staff vaccination process to address all facility staff, including agency staff who provided care, treatment and other services to facility and/or residents. Specifically, the facility failed to obtain the vaccination status of outside providers. The facility did not have the vaccination status for all of the outside providers listed on the matrix. The facility was unable to provide a listing of the vaccination status of all contracted providers/staff who enter the facility on a regular basis and provide direct care to residents. Cross-reference F880 infection control.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the resident had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for two (#39 and #262) of eight out of 33 sample residents. Specifically, the facility failed to: -Have accurate physician orders regarding code status for Resident #39; -Indicate code status, and have physician orders, in the electronic medical record (EMR) for Resident #39; and, -Initiate and formulate a medical orders for scope of treatment (MOST) form for Resident #39 and #262, used by the facility to form the resident's advance directives.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#24) of three residents reviewed for respiratory services out of 33 sample residents, received respiratory care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, Resident #24 was admitted with a laryngectomy (removal of all or part of the larynx /voice box), which was completed several years ago. Resident #24 did not have physician orders, respiratory assessment, and a person-centered care plan regarding his respiratory needs.

Inspectors wroteBased on observations, and interviews, the facility failed to ensure medication error rate was not greater than five percent. Specifically, the facility's medication error rate was 20 percent with five errors out of 25 opportunities.

Inspectors wroteBased on observations, record review and interviews, the facility failed to keep one (#15) of 11 out of 33 sample residents fwere [NAME] of any significant medication errors. Specifically, the resident's identity was not checked prior to medication administration. Resident #15 was going to be administered medications that were not intended for him which included hypertension, anti seizure and thyroid medication.

Inspectors wroteBased on observation, record review and interviews the facility failed to maintain communication with the hospice provider, including how the communication would be documented between the facility and the provider for one (#53) of two residents reviewed for hospice care services out of 33 sample residents. Specifically, the facility failed to collaborate with the hospice provider and maintain an effective plan of communication for the coordinated plan of care for Resident #53.

Inspectors wroteBased on observations, record review and interviews, the facility failed to develop and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to ensure proper wearing of masks and eye protection for staff.