Complete Care at Brackenville LLC

Inspectors wroteBased on interview, record review, and policy review, the facility failed to thoroughly investigate allegations of abuse for four residents (Resident (R) 59, R88, R97, and R106) out of nine residents reviewed for abuse in a total sample of 40. This failure placed residents at risk of further abuse and a diminished quality of life.

Inspectors wroteBased on observation, interviews, record review, review of facility policies, and review of the manufacturer's manual, the facility failed to ensure pressure relieving air mattresses were correctly set according to the manufacturer's guidelines and residents' weights for three of five residents (Residents (R) 5, R48, and R85) reviewed for pressure ulcers out of a total sample of 40 residents. This failure placed residents at risk for skin breakdown, delayed wound healing, pain, infection, and potentially avoidable complications.1. Review of R5's Face Sheet, located in the electronic medical records (EMR) under the Profile tab, revealed an admission date of 10/17/25 with the following diagnoses: myocardial infarction (heart attack) type 2, atypical atrial flutter (heart arrythmia), unspecified dementia, and reflux disease. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure accommodation of needs for two of two residents (Resident (R) 71 and R5) in the sample of 40. Specifically, the facility failed to address necessary wheelchair repairs for R71 and did not provide R5 with access to a functioning call light. This created a potential risk for resident injury.

Inspectors wroteBased on record review, staff and resident interviews, and policy review, the facility failed to ensure hearing services were provided for one of one resident (Resident (R) 97 reviewed for vision and hearing services. The facility's failure to ensure the provision of timely hearing services had the potential to negatively impact R97's ability to effectively communicate. A total of 40 residents were reviewed in the sample.

Inspectors wroteBased on record review, observations, staff interviews, and facility procedure review, the facility failed to ensure the routine provision of ordered respiratory services for one resident (Resident (R) 89) of two residents reviewed for respiratory services. The facility's failure created the potential for R89 to develop complications related to the ineffective administration of oxygen. A total of 40 residents were reviewed in the sample.

Inspectors wroteBased on record review, observations, interviews, and review of the facility policies, the facility failed to ensure staff followed enhanced barrier precautions (EBP) and standard nursing precautions while providing care for one of one resident reviewed on EBP (Resident (R) 5). Specifically, a Certified Nurse Aide (CNA) failed to follow personal protective equipment (PPE) guidelines and wear a gown and gloves while performing incontinent care. This failure had the potential to cause further infection to the resident's wounds.

Inspectors wroteBased on record review and interview, it was determined that for one (R2) out of three residents sampled for care plans, the facility failed to develop a person-centered care plan for the refusal of medications.

Inspectors wroteBased on record review and interview, it was determined that for one (R5) out of three residents sampled for acceptable standards of clinical practice, the facility failed to ensure that R5's medication was administered according to the physician's order.

Inspectors wroteBased on record review and interview, it was determined that for one (R5) out of three residents sampled for medication administration, the facility failed to ensure that R5's medication was administered per the physician's order.

Inspectors wroteBased on interview and record review, the facility failed to act promptly on the grievances and recommendations of the resident council group for seven of 12 months of resident council minutes reviewed and to the extent practicable, the facility staff failed to revise or develop new policies related to resident rights, life, and care. These failures resulted in resident concerns going unaddressed.

Inspectors wroteBased on observation, record review, interviews, and facility policy review, the facility failed to determine if one of one resident (Resident (R) 66) was assessed as clinically appropriate to self-administer medications of 38 sample residents. The failure of the facility to leave medications at the bedside unattended prior to an assessment, created an unsafe environment for the residents and other residents in the area.

Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to ensure the accurate code status was documented and available for reference for two of 36 sampled residents, (Resident (R)49 and R38). This deficient practice could result in not following the specific residents' wishes documented in the advanced directive.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received alternative measures prior to installation of side rails for one of one resident reviewed for side rails (Resident (R) 9) of 38 sampled residents. The lack of alternate side rail measures could lead to potential safety concerns related to bed rail use for residents with bed rails.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to ensure call lights were answered timely for one of 38 sample residents (Resident (R) 44) reviewed for staffing. This failure had the potential to put the residents at risk.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure that supervision to prevent accidents for one Resident (R) 297 out of four sampled residents reviewed for accidents. This failure caused actual harm, when R297 sustained a subdural hematoma after a fall when Certified Nursing Assistant (CNA)1 left the resident sitting on the bedside, unattended, while gathering supplies for the resident's personal care.

Inspectors wroteBased on record review and interviews the facility failed to have sufficient staff on a 24-hour basis to care for residents' needs, as identified through the facility assessment staff-to-resident ratios and the Payroll Based Journal (PBJ) Staffing Data Report supplied from the Centers for Medicare and Medicaid Services (CMS), resident council minutes, and views from the resident group. Additionally, the facility failed to respond in a timely manner to the needs of six residents (R)1, R44, R59, R33, R50, and R89 reviewed out of a total sample of 22.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure the food was palatable for four of 22 sampled residents (Resident (R)1, R59, R33, and R65) and residents attending Food Committee meetings. The food was not at a palatable temperature when residents received their meals; condiments were not consistently provided, and food was not flavorful/prepared properly.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure there was not more than a 14-hour time span between dinner and breakfast the next day. This failure affected approximately 19 residents out of 99 total residents, who ate in the west dining room. The extended time between dinner and breakfast had not been approved by the resident group.

Inspectors wroteBased on observation, interview, record review, policy review, and review of the US (United States) Food Code, the facility failed to ensure the kitchen was maintained in a sanitary condition to prevent the potential spread of foodborne illness to 97 out of 99 residents. Specifically, the facility failed to maintain a sanitary kitchen; label, date, and store food properly; use the handwashing sink for handwashing only and ensure a garbage can was in place; ensure equipment was clean; ensure staff followed hand hygiene/glove use standards; and ensure staff had their hair covered. The facility failed to ensure proper infection control practices were maintained for a sugar and a flour container which held scoops previously used by the kitchen staff. [...]

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to ensure elopement risks and wander guard assessments were updated to promote dignity for one Resident (R) 301 of two reviewed for elopement risk and wander guard use. The facility failed to ensure Certified Nursing Assistant (CNA)3 closed the privacy curtain while providing personal care to R39. R39's breasts and brief were exposed to public view. Additionally, R89 was not provided an opportunity for dignity when she sat in her wheelchair, while wearing a brief for over an hour.

Inspectors wroteBased on observations, interview, record review, and facility policy review, the facility failed to assess one of one sampled resident (Resident (R) 65) for self-administration of medications. This failure led to medications being left at the bedside where they could be accessed by other residents.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure residents were protected from verbal abuse by staff for one resident (R)59 of seven residents reviewed for abuse in a total sample of 22 residents.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure that an allegation of neglect was reported to the State Survey Agency (SSA) in a timely manner for one resident (Resident (R) 297) reviewed for abuse/neglect in a total sample of seven residents. This failure had the potential for other allegations of abuse/neglect to not be reported in a timely manner. (Cross Reference F689)

Inspectors wroteBased on interview, record review, and review of the facility policy, the facility failed to ensure that a thorough investigation of an allegation of staff-to-resident verbal abuse for one resident (R)346 of seven residents reviewed for abuse in a total sample of 22 residents.

Inspectors wroteBased on record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure two (Resident (R) 70 and R26) out of 40 sampled residents had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly could potentially lead to inaccurate assessment and care planning of the resident.

Inspectors wroteBased on interviews, clinical record review, and facility policy review, the facility failed to ensure that a biopsied specimen for one Resident (R) 298 of one residents reviewed for surgical procedure in a total sample of 22 residents was handled properly after a surgical procedure and not destroyed prior to analysis by pathology.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to provide respiratory care per standards of practice for two of two sampled residents (Resident (R) 91 and R16). Specifically, the facility failed to ensure respiratory equipment was stored properly for R91 and R16. The failure to store respiratory equipment consistent with professional standards had the potential to cause contamination and damage to the respiratory equipment.

Inspectors wroteBased on record review, observations, interviews, and review of the facility assessment, the facility failed to ensure one Certified Nursing Assistant (CNA)3 was competently trained to provide one Resident (R)39 personal care in a dignified manner (Cross Reference F550). Additionally, the facility failed to ensure one Licensed Practical Nurse (LPN) 5 was competent to handle a biopsied specimen and not to destroy it prior to analysis by a pathologist (Cross Reference F684).

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure one of two medication rooms was secured by closing and locking the door to the room. This failure had the potential of permitting unauthorized individuals access to the medication storage room.

Inspectors wroteBased on record review, observation, interviews, and policy review for four of 11 (Residents (R) 22, 91, 400, and 401) reviewed for medication administration, the facility failed to ensure the Evencare G3 glucometer used for diabetic monitoring was cleaned and disinfected per the manufacturer's instructions, failed to ensure hand hygiene was performed by one staff per facility policy, failed to store trash and personal belongings per infection control practices, and failed to wear Personal Protective Equipment (PPE) per facility policy for three staff. This failure puts residents and staff at potential risk of developing infections.