Brookdale Galleria

In the surveyor’s words

From the most serious findings on record at Brookdale Galleria, in the surveyor’s own words.

• Immediate jeopardy, patternF580Apr 4, 2024

  Based on interview and record review the facility failed immediately consult with the resident's physician when there is a significant change in the resident's physical status for 1 (Resident #1) of 5 residents reviewed physician notification. Facility staff identified sacral wound on Resident #1 on 2/16/2024 and facility staff failed to perform and document a wound assessment, notify the physician, and obtain wound care orders until 4 days later 2/20/2024. An IJ was identified on 4/1/2024. The IJ template was provided to the facility on [DATE] at 4:14pm. The Immediate jeopardy was removed on 4/4/2024 due to the facilities implemented actions that corrected the non-compliance. […]

• Immediate jeopardy, patternF686Apr 4, 2024

  Based on interview and record review the facility failed to ensure that a resident reviewed for pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for 1 (Resident #1) of 5 residents. 1. Facility staff identified sacral wound on Resident #1 on 2/16/2024 and facility staff failed to perform and document a wound assessment, notify the physician, and obtain wound care orders until 4 days later on 2/20/2024. Wound Care Physician assessed Resident #1 on 2/22/2024 and diagnosed Resident #1 with an unstageable (Due to Necroses) Sacrum Full Thickness pressure wound with a surface area of 129.72 cm. 2. Facility staff were performing dressing changes without a physician's order. […]

• Immediate jeopardy, isolatedF689Mar 23, 2026

  Based on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision for 1 of 8 residents (Resident #1) reviewed for adequate supervision. The facility failed to ensure that Resident #1 received adequate supervision when Resident #1 was able to exit the facility at 1:00am and found by staff on a busy street. An Immediate Jeopardy (IJ) was identified on 3.20.2026. The IJ template was provided to the Administrator on 3.20.2026 at 5:48 p.m. […]

• Actual harm, patternF686Dec 11, 2023

  Based on observation, interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to promote healing, prevent infection and prevent ulcers from developing for 1 (Resident #2) of 11 residents reviewed for treatment of pressure ulcer. -The facility failed to provide treatment in a timely manner for Resident #2 who experienced a decrease in skin integrity to the sacral region that resulted in an unstageable wound to the sacral region diagnosed by the wound care doctor on 12/1/23. -The facility failed to do consistent weekly skin assessments on Resident #2. […]

• Actual harm, isolatedF686Dec 17, 2024

  Based on interview, and record review, the facility failed to ensure 1 of 6 residents (Resident #1) reviewed for wound care received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing, in that: - The facility failed to identify a healed area to Resident #1's sacrum which included a scab and pink skin when Resident #1 admitted to the facility on [DATE]. Appropriate interventions were not implemented for Resident #1 and the area developed into a pressure ulcer within approximately 12 days of admission and eventually developed into a Stage IV pressure ulcer. - CNA B stated she did not reposition the resident frequently enough while working with Resident #1 upon her first few days admission. […]