Brook Stone Living Center

In the surveyor’s words

From the most serious findings on record at Brook Stone Living Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Aug 25, 2023

  Based on record review and resident, staff, Responsible Party (RP) and law enforcement officer interviews, the facility failed to protect a cognitively impaired resident (Resident #1) from physical abuse from an employee when Nursing Assistant (NA) #1 was witnessed by another employee, Personal Care Assistant (PCA) #1, with both hands around Resident #1's neck in response to the resident being combative with care. Resident #1 did not have the cognitive capacity to express an adverse outcome. A reasonable person would have been traumatized by being physically abused by their caregiver in their home environment. This occurred for 1 of 2 resident reviewed for abuse. Immediate Jeopardy began on 08/09/23 when the facility failed to protect Resident #1's right to be free from abuse. […]

• No harm, potential for more than minimal, widespreadF809Jan 20, 2023

  Based on staff interviews, consultant Registered Dietitian (RD) interview, and record review, the facility failed to serve a nourishing snack at bedtime when the time between dinner and breakfast was greater than 14 hours for residents residing on 2 of 2 resident hallways (100 Hall and 300 Hall). The findings included: A review of the facility's [NAME] Stone Living Center Meal Times indicated the food line start times were scheduled as follows: -The meal line for the 300 Hall was scheduled to begin at 4:45 PM for Dinner and at 7:15 AM for Breakfast (indicative of a 14 hour and 30 minute time span between the two meals); -The meal line for the 100 Hall Cart 1 was scheduled to begin at 4:50 PM for Dinner and at 7:30 AM for Breakfast (indicative of a 14 hour and 40 minute time span between… […]

• No harm, potential for more than minimal, widespreadF801Oct 6, 2021

  Based on record review and staff and consulting Dietitian interviews the facility failed to employ a clinically qualified nutritional professional on a full time basis when the currently employed dietary manager's certificate was expired. The affected 33 of 33 resident who received meals from the dietary department. The findings included: During an interview with the Dietary Manager on [DATE] at 4:20 PM she stated she was not currently a certified dietary manager because her certificate expired. She stated she had worked at the current facility for the last 2 years. A review of the certificate from the Certifying Board for Dietary Managers provided by the Dietary Manager revealed it expired on [DATE]. […]

• No harm, potential for more than minimal, widespreadF803Oct 6, 2021

  Based on observations, staff and consulting Dietitian interviews, and record review the facility failed to have planned menus which included the correct foods and portions for the dietary staff to serve for 2 of 2 meal observations. This practice resulted in incorrect foods being served to residents. The findings included: A review of the Week 4 Spring Summer 2021 menu provided by the facility revealed on day 2 (Tuesday 10/5/21) the breakfast meal was fried egg patty, sausage link, cold cereal, toast/jelly, juice milk, coffee. There were no portions sizes or clarifications for therapeutic diets. A review of the Day 2 Week 4 menu (Tuesday 10/5/21) spread sheet approved by the consulting Registered Dietitian revealed a breakfast menu of 4 ounces of assorted juice. […]

• No harm, potential for more than minimal, patternF761May 1, 2024

  Based on observation, record review, and staff interview the facility failed to remove expired medications from the refrigerator for 2 of 2 med rooms. Findings included: 1a. An observation on 05/01/24 at 1:31 PM in the presence of the Director of Nursing (DON) revealed the medication room [ROOM NUMBER] (100 hall) refrigerator had 5 expired antibiotics. There were 2 expired Intravenous (IV) antibiotic infusion doses for a resident who was no longer in the facility with the expiration date of 4/8/24. An additional 3 expired IV antibiotic infusion doses were found for another resident with an expiration date of 4/19/24. 1b. […]