River Brook Healthcare Center

Inspectors wroteBased on record review, staff interviews, the facility failed to ensure that two of three sampled residents (R) (R2 and R7) received a 30 day discharge notice and failed to notify the ombudsman of a facility initiated transfer or discharge.1. Review of the admission Record revealed Resident 2 (R2) was admitted to the facility on [DATE] with diagnoses including, but not limited to, hypertension, depression, diffuse traumatic brain injury with loss of consciousness, and traumatic ischemia of muscle. Review of the Progress Notes dated 01/10/2026 through 01/20/2026 revealed an entry dated 01/19/2026 indicating that R2 was accepted to an out of county (named) facility. The note stated that R2 and a family member were informed of the discharge, and the nurse and CNA were also notified of the transfer. Staff were informed that transport would arrive at 8:30 AM. [...]

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled, RAI/Care Planning Management, the facility failed to ensure that two of three sampled residents(R) (R2 and R7), whose care plans indicated they wished to remain in the facility, had their expressed desires honored.

Inspectors wroteBased on staff interview, record review, and review of the facility policy titled The Care Plan, the facility failed to implement the care plan interventions related to falls for one of five residents (R) (R12). This failure resulted in actual harm on 9/19/2025, when R12 had a fall from her bed, resulting in two fractured ribs, a hematoma to the right side of her head, and a laceration to her upper lip.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure one of five residents (R) (R12) was free from falls with major injury. This failure resulted in actual harm on 9/19/2025 when R12 had a fall from her bed, resulting in two fractured ribs, a hematoma to the right side of her head, and a laceration to her upper lip.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled Medication Administration, the facility failed to ensure the disposal of expired and discharged medications in one of one drug storage rooms.

Inspectors wroteBased on observations, staff interview, and review of facility documentation, the facility failed to ensure a safe/clean and comfortable environment by not initiating roof repairs required after known damage following most recent hurricane activity in 2024. The facility also failed to ensure air condition units in residents' rooms (2B and 3B)on one of three halls (200 Hall) were maintained to include cleaning and repair.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled Medication Administration, the facility failed to assess one of four sampled residents (R) (R50) for the ability to self-administer medications before leaving medications at the bedside.

Inspectors wroteBased on resident and staff interviews and record review, the facility failed to exercise confidentiality related to the medical care for one of 42 sampled residents (R) (R64).

Inspectors wroteBased on observations, interviews, and review of the facility policy titled Restraint Policy, the facility failed to assess the use of a Geri chair as a potential restraint device for one of three sampled residents (R) (R49) reviewed for potential restraint use.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure that privacy curtains provided full visual privacy in four of 20 sampled resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]).

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that the person in the role of the Infection Preventionist (IP) completed specialized training in Infection Prevention and Control. This failure placed all residents at risk for the potential transmission of infections and communicable diseases. The facility had a census of 68 residents.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure enhanced barrier precautions (EBP) were implemented for three residents (R) (R2, R3, and R4) who had pressure ulcers from a total sample of seven residents.

Inspectors wroteBased on staff interview, record review, and review of the Arbitration Agreement, the facility failed to ensure that the Arbitration Agreement presented to Residents (Rs) and Resident Representatives (RRs) during admission included a clause that a mutually convenient venue for the Arbitration would be selected. This failure affected all 73 residents of the facility who had signed the Arbitration Agreement and any future residents who might sign the agreement.

Inspectors wroteBased on staff interview, record review and review of the facility policy titled, Behavior Management Standard, the facility failed to ensure the resident, his or her family, and/or the resident representative (RR) was provided information related to the risks and benefits for psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) for four of five residents reviewed for unnecessary medications (Resident (R) 10, R53, R59, and R19).

Inspectors wroteBased on staff interviews, and record review, the facility failed to ensure that three Resident (R) 27, R16 and R19) of 24 sampled residents and/or their representatives were informed and provided written information to formulate an advanced directive.

Inspectors wroteBased on observation, resident interview, staff interview, record review, and review of the facility policy titled, Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, the facility failed to protect the resident's right to be free from physical abuse by another resident for one of two residents reviewed for abuse (Resident (R) 41).

Inspectors wroteBased on staff interview and record review, the facility failed to develop a comprehensive care plan directing measurable goals and interventions for two of 24 residents (Resident (R) 9 and R42) reviewed for care planning. This failure placed residents at risk for unmet care needs and the inability to meet their maximum practicable level of functioning.

Inspectors wroteBased on resident interviews, staff interviews, record review, and review of the facility policy titled, Trauma Informed Care the facility failed to ensure that one resident (Resident (R) 19) of one reviewed for trauma received trauma-informed care. The facility failed to ensure a behavioral health consult occurred after the resident triggered 10 of 10 indicators on a trauma screen conducted by the facility.

Inspectors wroteBased on staff interview, and record review, the facility failed to maintain an accurate medical record for one of 29 residents (Resident (R)38). Specifically, R38's code status was not accurately documented throughout the electronic medical record (EMR). The failure to document a resident's code status accurately in the EMR had the potential to result in a resident not receiving cardiopulmonary resuscitation (CPR) or receiving CPR when they should not, according to their documented wishes.