Brookdale Alliance

Based on record review and interview, the facility failed to maintain a separate criminal background check log. This had the potential to affect all 28 residents residing in the facility.

Findings include:

Review of facility personnel files revealed no evidence a criminal background check log had been maintained for employees.

Interview on 07/09/24 at 1:03 P.M. with the Administrator confirmed there was no criminal background check log in the facility.

Based on record review and interview, the facility failed to ensure all requirements of fire drills were completed. This had the potential to affect all 28 residents residing in the facility.

Findings include:

Review of fire drill documentation provided by the facility revealed fire drills were conducted on first shift on 10/10/23 and 02/01/24. There was no documented evidence that any other fire drills were conducted on first shift. There was also no documented evidence that the fire drills conducted included a verification of the signal was received by the alarm transmission company.

Interview on 07/09/24 at 10:39 A.M. with the Administrator confirmed there was no documented evidence the alarm company received the signal for any fire drills, and there was no documented evidence that any other fire drills were conducted on first shift other than on 10/10/23 and 02/01/24.

This violation is a recite to the survey completed 12/14/22.

Based on record review and interview, the facility failed to educate residents regarding fire safety as required. Had the potential to affect all 28 residents residing in the facility.

Findings include:

Interview on 07/9/24 at 2:06 P.M. with the Administrator revealed fire safety was usually reviewed during Resident Council.

Review of the Resident Council minutes dated 04/18/24, 05/23/24, and 06/12/24 revealed no documented evidence fire safety education was provided to residents.

Interview on 07/09/24 at 3:18 P.M. with the Administrator confirmed she had no documented evidence to verify resident fire safety had occurred.

Based on record review, interview, facility self-reported incident (SRI) review, and facility policy review the facility failed to prevent staff-to-resident abuse. This affected one resident (#1) of five residents reviewed for abuse. The facility census was 28.

Findings include:

Review of the medical record for Resident #1 revealed an admission date of 02/14/20 with diagnoses including restlessness, agitation, and hyperlipidemia.

Review of the activities of daily living (ADL) assessment dated 05/15/24 revealed Resident #1 was dependent on care for all ADL except for using the phone, which required hands on assistance.

Review of the facility SRI tracking number 248621 dated 06/11/24 revealed Caregiver #202 and Caregiver #203 were changing Resident #1 when Resident #1 began squeezing Caregiver #202's hand and tried to dig her nails into her. Caregiver #202 slapped Resident #1's hand and told her to stop. Resident #1 was assessed and all other residents as well as employees were interviewed and educated on abuse. Resident #1 suffered no apparent injuries. As a result of the investigation, Caregiver #202 was placed on suspension and ultimately terminated. The facility substantiated the allegation of abuse.

Interview on 07/09/24 at 10:28 A.M. with the Administrator confirmed the incident involving Resident #1 and Caregiver #202 resulted in substantiated abuse.

Interview on 07/09/24 at 10:39 A.M. with Resident #1 and her daughter revealed no knowledge of the incident. Resident #1 could not say whether she felt safe in the facility. Resident #1's daughter felt the aides treated her mom with respect and she had no concerns regarding abuse. She did reveal she thought some of the aides might be a little rough with her mom at times.

Review of the facility policy titled Abuse, Neglect and Exploitation

Based on record review and interview, the facility failed to ensure four fire drills were completed on afternoon shift. This finding had the potential to affect all 33 residents residing in the facility.

Findings include:

Review of the fire drills revealed completion of second shift fire drills on 02/28/22, and 05/31/22. There were no additional fire drills completed on second shift for 2022.

Interview on 12/14/22 at 09:16 A.M. with the Wellness Director verified second shift fire drills were completed on 02/28/22 and 05/31/22, and that there were no additional fire drills completed on second shift between 12/2021 to 12/2022.