Brookwood Care Community

Based on medical record review, resident trust document review, and staff interview, the facility failed to ensure authorizations to manage resident funds were attested to by a witness not affiliated with the facility in any manner. This affected one (#31) of five residents reviewed for resident funds. The facility census was 76.

Findings include-

Review of the medical record revealed Resident #31 was admitted to the facility on 03/19/11. Diagnoses included schizophrenia, weakness, and paranoid schizophrenia.

Review of the most recent assessment dated 06/05/25 revealed Resident #31 was alert and oriented and had no negative behaviors. Resident #31 was independent with mobility, personal hygiene, dressing, and bathing.

Review of Resident #31's authorization form for managing funds dated 08/09/21 revealed it contained no witness signature.

Interview on 10/16/25 at 11:22 A.M. with Business Office Manager (BOM) #70 confirmed the authorization form for managing resident funds for Resident #31 was missing a witness signature.

Based on medical record review and staff interview, and policy review, the facility failed to ensure a resident's sponsor was notified of a fall incident. This affected one (#22) of five resident records reviewed for falls. The facility census was 76.

Findings include:

Review of the medical record revealed Resident #22 was admitted to the facility on 11/02/20. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, major depressive disorder, aphasia, and lack of coordination.

Review of the most recent assessment dated 06/05/25 revealed Resident #22 was alert and oriented, had no negative behaviors, required minimal assistance with medication, was independent with personal hygiene and toileting, and needed assistance with bathing.

Review of Resident #22's service plan dated 11/21/24 revealed the resident was independent with continence care, required assist with bathing, was independent in dressing, and used a wheelchair for mobility.

Review of Resident #22's progress notes dated 08/12/25 revealed the resident was sent to a local hospital emergency room (ER) for evaluation after an unwitnessed fall out of a wheelchair in the smoking area. The resident was admitted to the hospital for treatment of pneumonia.

Review of the Resident #22's physician progress notes dated 08/13/25 revealed the resident returned to facility via stretcher and the resident was alert and oriented per baseline. The resident denied any pain associated with the fall and was reoriented to the call light system.

Review of Resident #22's medical record revealed no documentation of notification of an unwitnessed fall to the resident's sponsor or documentation of the resident's refusal to have the sponsor notified.

Interview on 10/20/25 at 3:20 P.M. with Corporate Clinical Analytics (CCA) #67 revealed there was no documentation of notification to Resident #22's sponsor regarding the fall on 08/12/25.

Review of the policy for accident and incident reporting, dated 09/2018, revealed accidents or incidents involving a resident that result in an injury are reported to his or her physician and reported to the family or legal representative. The nurse documents the condition of the resident in the medical record.

Based on medical record review, staff interview, review of an incident log, and policy review, the facility failed to investigate fall incidents and identify interventions to prevent further falls, and failed to ensure fall incidents were documented on the incident log separate from the resident record. This affected two (#22 and #71) of five resident records reviewed for falls. The facility census was 76.

Findings include:

1. Review of the medical record revealed Resident #22 was admitted to the facility on 11/02/20. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, major depressive disorder, aphasia, and lack of coordination.

Review of the most recent assessment dated 06/05/25 revealed Resident #22 was alert and oriented, had no negative behaviors, required minimal assistance with medication, was independent with personal hygiene and toileting, and needed assistance with bathing.

Review of Resident #22's service plan dated 11/21/24 revealed the resident was independent with continence care, required assist with bathing, was independent in dressing, and used a wheelchair for mobility.

Review of Resident #22's progress notes dated 08/12/25 revealed the resident was sent to a local hospital emergency room (ER) for evaluation after an unwitnessed fall out of a wheelchair in the smoking area. The resident was admitted to the hospital for treatment of pneumonia.

Review of the Resident #22's physician progress notes dated 08/13/25 revealed the resident returned to facility via stretcher and the resident was alert and oriented per baseline. The resident denied any pain associated with the fall and was reoriented to the call light system.

Review of Resident #22's medical record revealed no documentation related to interventions for fall prevention implemented or an investigation into the fall on 08/12/25.

2. Review of the medical record revealed Resident #71 was admitted to the facility on 06/03/24. Diagnoses included unspecified dementia, anemia, edema, depression, malignant neoplasm of an unspecified kidney, hypoxemia, type two diabetes, and gross hematuria.

Review of the most recent assessment dated 06/04/25 revealed Resident #71 was alert and oriented, independent with personal hygiene and dressing, and needed assistance with bathing.

Review of the progress notes for Resident #71 dated 09/06/25 at 7:55 P.M. revealed a nurse was in the resident's room for morning medication pass when the resident was found lying on the floor in the kitchen area on his right side. There was blood noted on the floor and the back right side of Resident #71's head. Pressure was applied to the area and Resident #71 was alert and able to speak. Resident #71 indicated he did not know how he fell but thought he passed out and voiced increased pain. Emergency medical services were called and Resident #71 was transported to the hospital.

Review of Resident #71's medical record revealed no evidence of the fall from 09/06/25 being investigated.

Review of the facility incident log for the last 12 months revealed no documentation of Resident #22 or Resident #71's falls on the incident log.

Interview on 10/20/25 at 12:08 P.M. with Corporate Clinical Analytics (CCA) #67 confirmed there was no documented investigation completed for Resident #22 or Resident #71's for falls and the fall incidents were not logged on the incident log.

Review of the undated policy for fall management revealed staff will identify appropriate interventions to reduce the risk of falls. If falling occurs despite initial interventions, staff will implement additional or different interventions based upon circumstances of the fall. Each fall and interventions will be documented in the resident record.

Review of the policy for accident and incident reporting, dated 09/2018, revealed the Director of Nursing (DON)/designee should conduct a complete investigation of all accidents and document the new interventions in the medical record. Accidents or incidents involving a resident that result in an injury are reported to his or her physician and reported to the family or legal representative. The nurse documents the condition of the resident in the medical record.

Based on observation, staff interview, and policy review, the facility failed to store food items in a manner to prevent contamination and spoilage. This had the potential to affect all 76 residents residents residing in the facility. The facility census was 76.

Findings include:

Observation and interview on 10/16/25 beginning at 9:08 A.M. with Dietary Manager (DM) #20 revealed the walk-in refrigerator contained one large pan of cheese mashed potatoes with a made on date of 03/15. Interview with DM #20 at the time of discovery confirmed the expired food and disposed of it. Observation of the dry storage area revealed three large bins of flour, sugar, and rice, each with scoops contained inside the bins. DM #20 stated the bins should not have any scoops stored in them and confirmed the findings. Continued observation of the dry storage revealed five large bags of pasta on the shelf which were opened and not dated. Interview with DM #20 confirmed the opened and undated pasta bags and disposed of them.

Review of the policy titled, Dry storage areas

Based on observation and staff interview, the facility failed to maintain trash in garbage cans with tightfitting lids. This had the potential to affect all 76 residents. The facility census was 76.

Findings include-

Observation and interview on 10/16/25 at 9:08 A.M. with Dietary Manager (DM) #20 revealed two large trash cans without lids on them in the kitchen.

Interview with DM #20 verified the facility did not have have lids for the two trash cans at the time of the observation.

Based on observation and staff interview, the facility failed to maintain the smoking area free from potential fire hazards. This had the potential to affect all 76 residents. The facility census was 76.

Findings include-

Observation and interview on 10/16/25 at 10:20 A.M. with Director of Maintenance (DOM) #54 revealed the smoking area had no ashtrays. The smoking can was on the ground full of butts and four small pieces of paper contained in the same can.

Interview with DOM #54 confirmed the paper mixed in with the cigarette butts and stated the can needed to be emptied at the time of discovery.

Based on observations, interviews, and policy review, the facility failed to ensure food in the kitchen was stored properly. This had the potential to affect all 74 residents residing in the facility.

Findings include:

Observation on 12/12/24 at 11:14 A.M. of the walk-in refrigerator revealed bags of pepperonis and grated cheese that had not been labeled with a date, which was verified by Dietary Manager #2.

Observation on 12/12/24 at 11:18 A.M. of the ice cream freezer revealed a bag of chicken tenders that had not been labeled with a date, which was confirmed by Dietary Manager #2.

Observation on 12/12/24 at 1:56 P.M. of the walk-in freezer revealed an opened bag of hamburger patties that had not been labeled with a date, which was verified by Cook #40.

Review of the policy titled Food Storage reviewed 01/20/18 revealed all foods stored in the refrigerator or freezer will be covered, labeled, and dated.

Based on record review and interview, the facility failed to ensure residents capable of self-evacuation were evacuated during at least two fire drills per year on each shift. This had the potential to affect all 74 residents residing in the facility.

Findings include:

Review of the fire drills from 12/18/23 to 11/29/24 revealed third shift fire drills were conducted on 12/18/23, 03/31/24, 06/19/24, and 09/18/24, but there was only documentation of resident evacuations for the drill on 09/18/24.

Interview on 12/12/24 at 2:16 P.M. with Maintenance Director #60 verified there was documentation of resident evacuations for only one third shift fire drill on 09/18/24.