Continuing Care at Brooksby Village

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure two Residents (#48, #5) were free from unnecessary psychotropic medications by ensuring a reassessment of an as needed (PRN) psychotropic medication after 14 days, out of a total sample of 19 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to implement the plan of care for one Resident (#9) out of a total sample of 19 residents. Specifically, for Resident #9 the facility failed to place foam booties and hand rolls as ordered.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for two Residents (#68, #7) out of a total sample of 19 Residents. Specifically,For Resident #68, the facility failed to accurately reconcile medication orders on admission to the facility. 2. For Resident #7, the facility failed to change a dressing as ordered.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure professional standards of practice for Foley catheter care for one Resident (#48) out of a total sample of 19 residents. Specifically for Resident #48, the facility failed to ensure they obtained physician's orders for the correct indwelling catheter size.

Inspectors wroteBased on observation, record review and interview, the facility failed to accurately document in the medical record for two Residents (#7 and #9) out of a total sample of 19 residents. Specifically:For Resident #7 the facility documented that a treatment was completed when it was not. For Resident #9 the facility documented that foam booties and hand rolls were in place as ordered when they were not.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1) who had severe cognitive impairment, the Facility failed to ensure Resident #1 was free from the use of physical restraint when, on 05/24/25 around 6:15 A.M. Certified Nurse Aide #1 wrapped Resident #1's body from under the chest area to below the buttocks in a bed sheet to prevent him/her from accessing that area of his/her body.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who on 12/12/24 was noted by nursing to have a bruised area on his/her right arm, and reported to nursing that a staff member had been physically abusive with him/her during care, the facility failed to ensure staff implemented and followed their abuse policy, when although Nurse #1 immediately reported Resident #1's allegation to the Nurse Supervisor, the Nurse Supervisor did not immediately report the abuse allegation to the Director of Nursing, as required.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure its staff provided treatments in accordance with professional standards of practice for one Resident (#12) out of a total sample of 18 residents. Specifically, for Resident #12: 1. The facility failed to ensure a wound clinic appointment was re-scheduled to obtain new wound treatment interventions when requested by the Nurse Practitioner for a deteriorating right lower extremity wound, resulting in the wound continuing to deteriorate. 2. The facility failed to implement the physician's order to apply z-guard (a protective moisture barrier ointment) before soaking the right lower extremity wound in dakin's solution (a solution containing diluted bleach used topically in wound to reduce the risk of infection), resulting in pain and deterioration of the wound. 3. [...]

Inspectors wroteBased on review of the Facility Assessment, employee education record review, and interviews, the facility failed to implement mandatory training on Quality Assurance and Performance Improvement (QAPI) for 15 employees.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a dignified experience for Residents on one of two units. Specifically, the facility failed to ensure that staff did not speak a foreign language while in the presence of, and while providing care for, Residents on the Terrace unit.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for four Residents (#30, #52, #1, and #12) out of a total of 18 sampled residents. Specifically: 1. For Resident #30 the facility failed to ensure that the Resident's air mattress was set to the correct setting to promote wound healing. 2. For Resident #52, the facility failed to ensure a stage 2 coccyx pressure ulcer was assessed and measured weekly, as indicated in the Resident's plan of care and failed to have a physician's order for an air mattress. 3. [...]

Inspectors wroteBased on interviews, record review, staff education review, and facility assessment review, the facility failed to ensure the nursing staff were trained and demonstrated the competencies and skill sets necessary to provide the level and types of care and services needed as outlined in the Facility Assessment. Specifically, the facility failed to ensure licensed nursing staff were trained and demonstrated competency related to wound care.

Inspectors wroteBased on Facility Assessment review and staff interview, the facility failed to identify resources based on the resident population to determine the necessary care, support services, and educational resources (in-servicing) needed to care for residents. Specifically, the facility failed to address education resources and include a competency-based approach, including competencies necessary upon orientation and/or annually, to determine the knowledge and skills required among staff to ensure residents are able to maintain or attain their highest practicable physical, functional, mental, and psychosocial well-being and meet current professional standards of practice.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with activities of daily living (ADLs) for dependent residents for one Residents (#32) out of a total sample of 18 residents. Specifically, for Resident #32, the facility failed to provide supervision while eating.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure an environment free from accidents and hazards, for two Residents (#31 and #32) out of a total sample of 18 Residents. Specifically: 1. For Resident #31, the facility failed to ensure that the Resident had a urinal within reach per the Resident's care plan after the Resident had fallen and sustained a wrist fracture attempting to self-toilet in his/her bathroom. 2. For Resident #32, the facility failed to ensure that the Resident had non-skid strips and a fall mat next to the bed as ordered by the physician and as stated in the plan of care. Findings Include: Review of the facility policy titled Fall Management, dated April 2023, indicated the following: - To minimize and/or decrease the risk of falls through an interdisciplinary of guest/resident and to develop individualized care/service plan approaches. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide respiratory care services in accordance with professional standards of practice for one Resident (#310), out of a total sample of 18 residents. Specifically, the facility failed to obtain a physician's order for the use of a Continuous Positive Airway Pressure (CPAP) machine (a machine used to treat sleep apnea) for Resident #310 who had a diagnosis of sleep apnea.

Inspectors wroteBased on observation, interviews, and policy review, the facility failed to ensure transmission-based precautions were followed to prevent the spread of infections. Specifically, the facility failed to ensure staff appropriately donned (put on) a precaution gown while performing wound care for a Resident on enhanced barrier precautions (EBP).