Brookwood Skilled Nursing and Therapy

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure PICC line dressings were changed, and mid-arm circumference measurements were completed and documented every 7 days for 2 (#2 and #5) of 3 sampled residents reviewed for PICC line care and maintenance. The DON identified six residents with PICC lines.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensurea. residents received pain medication in a timely manner for 1 (#122) of 2 sampled residents reviewed for pain management. The prolonged wait time despite verbalizing increased pain to multiple staff resulted in harm for Resident #122 as evidenced by not wanting to complete ADL's due to pain; and,b. residents were consistently evaluated for the effectiveness of regularly scheduled pain medication for 1 (#101) of 2 sampled residents reviewed for pain management assessment and monitoring. The regional nurse consultant identified 42 residents received pain medication.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were provided with an option to not sign the arbitration agreement for 6 (#24, 31, 38, 46, 53, and #96) of 6 sampled residents reviewed for arbitration agreements. The administrator identified 114 residents had entered into a binding arbitration agreement.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure:a. EBP was followed during an incontinent care observation for 1 (#122) of 6 sampled residents reviewed for incontinent care; andb. ensure nasal cannulas were bagged when not in use and oxygen tubing was labeled with the date administered in order to prevent infections for 1 (#53) of 3 sampled residents reviewed for oxygen services. The regional nurse consultant identified 11 residents had O2 orders and 32 were on EBP.

Inspectors wroteBased on record review and interview, the facility failed to implement a comprehensive care plan intervention regarding pain monitoring for 1 (#101) of 18 sampled residents reviewed for care plan implementation.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure;a. oxygen tubing was dated with the administration date, andb. a nasal cannula was bagged when not in use for 1 (#53) of 3 sampled residents reviewed for oxygen services. The corporate nurse identified 11 residents had physician orders for oxygen therapy.

Inspectors wroteOn 01/02/25 an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure Resident #2 who had insulin dependent type 2 diabetes mellitus with hypoglycemia was assessed, monitored, and provided medication for hypoglycemia as ordered by the physician and outlined in their care plan. Resident #2 was admitted to the facility on [DATE] with orders for routine insulin administration and insulin to be administered per sliding scale. Resident #2 also had orders for blood sugar to be checked via fingerstick twice a day and as needed for signs or symptoms of hypoglycemia and to give Glucagon (oral gel or IM) (glycogenolytic agent) if blood sugar was less than 70. On 12/26/24 at 6:09 a.m., Resident #2 had a blood sugar reading of 68 and the nurse did not administer the Glucagon gel as ordered. [...]

Inspectors wroteOn [DATE] an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to promptly notify the physician of Resident #2's laboratory results which fell outside of clinical reference ranges and showed a deterioration in their condition. Resident #2 was admitted to the facility on [DATE] with diagnoses which included urinary tract infection (ESBL) and pneumonia and was receiving antibiotic therapy. Resident #2's admission lab results, dated [DATE], documented WBC 11.3 (Ref range 3.98-10.04) and Neutrophil # 7.7 (Ref range 1.56-6.13). The report was signed by the physician. Resident #2's follow-up lab results, dated [DATE], documented WBC 26.2 (Ref range 3.98-10.04) and Neutrophil # 19.7 (Ref range 1.56-6.13). There was no documentation the results were reported to the physician. On [DATE], Resident #2 was transferred to the emergency room. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the physician was notified for blood sugars outside of parameters as ordered for two (#1 and #3) of three sampled residents whose clinical records were reviewed for notification of changes. The administrator identified 111 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was free from verbal and willful physical abuse from another resident with uncontrolled abusive behavior for one (#1) of three sampled residents reviewed for abuse. The administrator identified 104 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to report an allegation of resident to resident abuse to OSDH for two (#1 and #2) of three sampled residents reviewed for abuse. The administrator identified 104 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, and the facility failed to consult/notify the physician of missed antibiotic therapy for a resident with possible osteomyelitis for one (#59) of one sampled resident reviewed for antibiotic use. The Administrator identified 106 residents resided in the facility. The DON identified 13 residents received antibiotics.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure MDS assessments were accurate for four (#59, 6, 34, and #61) of 22 sampled residents reviewed for MDS accurate assessments. The Administrator identified 106 residents resided in the facility. The DON identified four residents with diabetic ulcers.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure: a. coordination of care with hospice for one (#61) of one sampled resident reviewed for hospice, b. wound care treatments were administered as ordered for two (#56 and #59), c. a referral was made to a wound care center as ordered for one (#59) of five sampled residents reviewed for wounds, d. a resident was in the dining room for all meals related to weight loss for one (#18) of 22 sampled residents reviewed for following physicians' orders, and e. lab tests were obtained as ordered for HgBA1C every three months for one (#8) of 22 sampled residents reviewed for following physicians orders. The Administrator identified 106 residents resided in the facility. The DON identified four resident had diabetic ulcers and 21 had hospice services.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure pressure ulcer treatment were provided as ordered for one (56) of three sampled residents reviewed for pressure ulcers. The Resident Matrix, dated 04/30/24, documented 13 residents had pressure ulcers.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure: a. an individual narcotic count sheet was correct for one (#59) of three narcotic counts completed, and b. eight hour verification sheets was signed by staff at shift change for one of four sampled medication carts. The Administrator identifed 106 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control was maintained during medication pass, when staff were observed to touch medications with their bare hands for two (CMA #1 and CMA #2) of three CMA's observed preparing medications. The Administrator identified 104 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure information was offered to formulate an advanced directive for one #(61) of three sampled residents reviewed for advance directives. The Administrator identified 106 residents resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure a mattress was not soiled for one (#70) of eight mattresses observed for homelike environment. The administrator identified 106 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive assessment was completed every 12 months for one (#73) of 22 sampled residents reviewed for assessments. The Administrator identified106 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure nail care was provided for one (#76) of three sampled residents reviewed for assistance with activities of daily living. The Administrator identified 106 residents resided in the facility. The DON identified 38 residents who were dependent on staff for assistance with ADL's.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure smoking products (lighter) were kept secure on the nurses cart for one (#211) of one sampled resident who required supervision while smoking. The Administrator identified 106 residents resided in the facility. The DON identified 15 residents who smoked, one resident required supervision.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure: A. nail care was provided for one (#12) and B. incontinent care was provided in a manner to remove all bowel movement for one (#58) of 11 sampled residents reviewed for ADLs.

Inspectors wroteBased on observation and interview, the facility failed to ensure a supply closet was locked for one of one supply closet observed and a sharps container was closed and not accessible to the residents for one of one cart observed. The Resident Census and Condition of Residents, report, dated 03/22/23, documented 110 residents resided in the facility.

Inspectors wroteBased on record review, observation and interview, the facility failed to honor a resident's choice of bathing for one (#25) of 11 sampled residents who were reviewed for ADLs. The Resident Census and Conditions of Residents report, dated 03/22/23, documented 110 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure procedure was followed for dispensing and administering peg tube medication for one (#212) of one sampled resident reviewed for peg tube medication administration. The Administrator identified six residents received medication through a peg tube.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure a medication cart was secured and the medication keys were kept with an authorized person for one of six medication carts observed. The Resident Census and Condition of Residents report, dated 03/22/23, documented 110 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a physician ordered UA was obtained for one (#90) of one sampled resident reviewed for physician ordered labs. The Resident Census and Condition of Residents report, dated 03/22/23, documented 110 residents resided in the facility.