BROOKDALE PARKPLACE

A relicensure survey was completed on 8/28/25. Deficiencies were cited.

Based on record review and interview the residence failed to have at least one staff member onsite at all times who was certified in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting 59 current residents. Findings include:On 8/26/25, the residence provided all CPR certifications for all certified staff; however, no staff were CPR certified on the following dates:8/22/25 morning and evening shifts. 8/23/25 evening shift. On 8/26/25 at 1:20 p.m., the administrator acknowledged there was no CPR-trained person on 8/22/25 morning and evening and 8/23/25 evening shifts, as required.

Based on record review and interview, the residence failed to document and implement effective actions that were to be taken by staff to prevent reoccurrence of falls, affecting three of four residents (#1, #2, #4) who fell. Specifically, Resident #1 fell 15 times in July and August 2025. Resident #1 fell on 8/1/25 and had a bruised leg and expressed pain. On 8/5/25 Resident #1 fell during the overnight shift and on 8/6/25 bruises were observed on his upper and lower back. On 8/23/25 Resident #1 fell and had an abrasion on his right forearm. Resident #1's care plan was last updated in May 2025 and did not include actions that were to be taken by staff to prevent reoccurrence of falls, nor were staff able to detail any resident specific actions to prevent reoccurrence of falls for Resident #1. Findings include:1. Resident #1 was admitted to the residence on 11/13/20 with diagnoses including insomnia and prostatic hyperplasia. Progress notes for Resident #1 in July and August 2025 revealed the following:On 7/17/25 Resident #1 fell on the floor next to his bed. On 7/23/25 Resident #1 fell on the floor next to his bed. On 7/24/25 Resident #1 expressed pain. On 7/25/25 Resident #1 was in a lot of pain, had a hard time walking and had swollen legs. On 7/27/25 Resident #1 fell twice at 3:15 p.m. and 8:32 p.m. On 8/1/25 Resident #1 fell on the floor near his recliner. Expressed pain in his legs in the evening. Swollen legs and a bruise on leg. On 8/2/25 Resident #1 unable to walk and expressed pain. On 8/2/25 at 11:43 a.m., Resident #1 fell on the floor near his recliner. On 8/3/25 Resident #1 fell trying to walk to the bathroom. On 8/5/25 Resident #1 fell on the overnight shift. On 8/6/25 Resident #1 had bruises on his upper and lower back and had pain in his left leg. On 8/10/25 Resident #1 fell in the bathroom. On 8/14/25 Resident #1 fell on the floor next to his bed. On 8/16/25 at 12:50 a.m. Resident #1 fell on the floor next to his bed. Resident #1 again at 5:50 a.m. On 8/16/25 an abrasion was discovered after fall on 8/15/25. On 8/18/25 at 3:00 a.m. Resident #1 rolled out of bed. On 8/19/25 at 8:20 p.m., Resident #1 fell on the floor next to his bed. On 8/20/25 Resident #1 reported pain and could barely walk. On 8/23/25 Resident #1 fell. Abrasion noted on his right forearm. Resident #1's care plan, last revised on 5/15/25, revealed he was a fall risk, and staff were to identify environmental fall risks, including clutter and furniture arrangement, lighting, and non-slip footwear. The care plan was not updated with additional effective actions that staff were to take to prevent reoccurrence of falls. On 8/27/25 at 7:56 a.m., Staff #6 said Resident #1 was at risk for falling and was required to watch him frequently and keep his door open. On 8/27/25 at 8:26 a.m., the resident care coordinator (RCC) identified Resident #1 as a fall risk and said he fell because he tried to get up and walk to the restroom to use the toilet. When asked what interventions were in place to prevent reoccurrence, the RCC said Resident #1 refused to use a bedside commode and refused to wear incontinence products. On 8/27/25 at approximately 4:00 p.m., Staff #1 acknowledged Resident #1 was a fall risk and she was told to keep his door open and keep an eye on him every 10 minutes. On 8/27/25 at 4:15 p.m., Staff #2 acknowledged Resident #1 was a fall risk and was told to keep an eye on him, listen to him, keep his door open and check on him every 30 minutes. She added he had only recently started falling in the last few months. On 8/28/25 at 9:05 a.m., Staff #4 acknowledged Resident #1 was a fall risk and said she was told to remind him to push his call pendant for help, to keep his room clean and to check on him every 15 minutes to ensure he did not get up on his own. On 8/28/25 at approximately 9:15 a.m., Staff #5 acknowledged Resident #1 was at risk for falling and said it was hard to prevent reoccurrence of falls because he is a hard resident and cannot stand well. On 8/28/25 at 9:31 a.m., the district director of clinical services said the care plans were required to be updated with fall interventions after falls and the care staff were trained to look at care plans in order to know what care residents required. On 8/28/25 at 10:15 a.m., the administrator said she expected the residence to update care plans with required action taken by staff to try and prevent falls. She added she expected the care plans to be more personalized and for staff to be able to speak to those personal interventions to prevent reoccurrence of falls. The administrator was aware that Resident #1 fell, but not approximately 15 times in less than three months. 2. Similar deficient practice was found onsite for Residents #2, #4 and #5.

Based on record review and interview, the residence failed to follow the residence's policies and procedures for the identification, reporting, and investigation of injuries of unknown origin, affecting three of four sample residents (#1, #4, #5). (Cross-reference U2230)Findings include:On 8/28/25 at approximately 10:15 a.m., the administrator was asked to provide the residence's investigation notes or supporting documentation for Resident #1, #4 and #5's skin abrasions and bruises that were progress noted by the residence in July and August 2025. Resident #1 was admitted to the residence on 11/13/20 with diagnoses including insomnia and prostatic hyperplasia. On 8/4/25 an external hospice representative documented that Resident #had a large bruise on his lower back. There was investigation for this injury of unknown origin or supporting documentation provided by the residence regarding how this large bruise occurred. A progress note in Resident #1's record, dated 8/6/25 read Resident #1 was in pain in his left outer thigh and left knee and had a small bruise on his upper and lower back. There was no investigation for this injury of unknown origin or supporting documentation provided by the residence in regards to how this small bruise occurred. On 8/28/25 at approximately 10:15 a.m., the administrator said she expected the residence care and nursing staff to note in progress notes their investigations of injuries of unknown origin. On 8/28/25 at approximately 12:15 p.m., the administrator was able to provide supporting documentation for some of the bruises and abrasions noted for Resident #1, #4 and #5., however, there was still missing documentation/investigation notes from Resident #1, #4, and #5's bruises or abrasions in July and August 2025.

Based on observation, interview and record review, the residence failed to ensure staff documented in progress notes all out-of-the-ordinary events or issues that affected the resident's physical, behavioral, cognitive, or functional condition, along with the action taken by staff to address the resident's changing needs, affecting three of four resident progress notes reviewed (#1, #2, #4). (Cross-reference U1412)Findings include:1. Resident #4 was admitted to the residence on 1/16/23 with diagnoses including dementia, Alzheimer's disease, muscle weakness, lack of coordination and protein-calorie malnutrition. Progress notes for Resident #4 in August 2025 revealed the following:On 8/12/25 Resident #4 stated she had pain in her buttocks. On 8/13/25 Resident #4 reported pain when she was being changed. On 8/15/25 an external hospice representative (EHR) noted Resident #4 was lethargic, had declining speech responsiveness and audible secretions. There were no other progress notes in Resident #4's record documented by the staff that included information on Resident #4's wellbeing or out of the ordinary event or issue that affected Resident #4's physical, behavioral, cognitive and or functional condition, along with the action taken by staff to address Resident #4's changing needs. Progress notes documented by an EHR in August 2025 revealed the following:On 8/22/25 Resident #4 was bed bound and declining and had an open area to her coccyx. On 8/22/25 Resident #4 was starting to transition towards the end of life. Resident #4 has had no food or fluid intake. Dressing applied to the pressure ulcer on coccyx. On 8/25/25 Resident #4 had an ongoing pressure ulcer on the coccyx.a. ObservationOn 8/28/25 Resident #4 was lying in her bed asleep.b. InterviewsOn 8/27/25 at 7:56 a.m., Staff #6 identified Resident #4 as having recently experienced a change in her baseline and was enrolled with an external hospice provider. On 8/27/25 at 8:26 a.m., the resident care coordinator did not identify Resident #4 as having an open wound when asked if any residents currently had open wounds. On 8/28/25 at approximately 10:15 a.m., the administrator said she expected the residence staff to document in the resident's progress notes after a resident fell, had a skin tear/abrasion, bruises and changes in their condition. She added she would have expected to see Resident #4's recent change in condition in her progress notes. 2. Similar deficient practice was found onsite for Resident #1 and #2.

A licensure revisit was completed on 2/20/23 for the previous deficiency cited on 8/16/22. The residence is in compliance with all regulations surveyed.

A licensure revisit was completed on 2/20/23 for all previous deficiencies cited on 7/12/22. The residence is in compliance with all regulations surveyed.

A licensure revisit was completed on 2/20/23 for all previous deficiencies cited on 5/18/22. The residence is in compliance with all regulations surveyed.