Brooke Knoll Village

In the surveyor’s words

From the most serious findings on record at Brooke Knoll Village, in the surveyor’s own words.

• Actual harm, isolatedF686Apr 30, 2021

  Based on record review and interview, the facility failed to identify, assess, and treat a pressure wound on a resident's right heel prior to discharge, resulting in harm when the resident had to have a surgical intervention and debridement for 1 of 4 residents reviewed for wounds (Resident C). Findings include: On 4/28/21 at 10:00 a.m., Resident C's daughter indicated she had taken the resident to her (the daughter's) home upon discharge, 2/21/21. Resident C had a cardiology appointment in the morning on 2/22/21. The resident had complained of pain in her heel. The physician looked at it and sent her to the wound center for immediate evaluation. The resident had not been able to see her own heel due to her recent right leg and hip surgery she was unable to bend or cross her leg. […]

• No harm, potential for more than minimal, patternF880Apr 9, 2026

  Based on observations, interviews, and record review, the facility failed to ensure enhanced barrier precautions were implemented per facility policy and ensure appropriate professional standards for infection prevention were implemented for 3 of 27 residents reviewed for infection control (Residents 105, 77, and 1). Findings include:1. On 4/6/26 at 10:32 a.m., Resident 105 was initially observed. He was lying in bed with an intravenous (IV) pole at bedside which ran to a peripherally inserted central catheter (PICC). A Foley catheter (urinary catheter) drainage bag was also noted to the side of his bed with dark yellow urine in it. On 4/8/26 at 9:30 a.m., Resident 105 was observed through his open door. […]

• No harm, potential for more than minimal, patternF550Mar 27, 2025

  Based on observations, interviews and record reviews, the facility failed to ensure residents had the right to privacy and dignity when staff failed to knock and announce themselves before entering the residents' room for 3 of 3 residents reviewed for dignity (Resident 25, 34, and 46), and for 1 of 1 resident council meeting (Residents 9, 20, 48, 11, and 43). Findings include: 1. During an interview on 3/24/25 at 10:25 a.m. with Resident 25, an unknown staff member opened the door without knocking and entered the room. The staff member indicated she was looking for Resident 25's roommate and then left abruptly. Resident 25 indicated a lot of staff members did not knock before they entered the room or the bathroom. […]

• No harm, potential for more than minimal, patternF761Mar 27, 2025

  Based on observation and interview, the facility failed to date medications when opened and label over the counter medications for 3 of 6 medication carts reviewed (Residents 34, 47, 5, 64, 49, 11, 44, and 59). Findings include: 1. Resident 34 had an insulin pen lispro in the cart dated [DATE]. It expired 28 days after opening. 2. Resident 47 had latanoprost eye drops in the medication cart with no date to indicate when they were open for 2 of 2 bottles observed. 3. Resident 5 had a bottle of nasal deep-sea spray in the cart with no date to indicate when it was opened. 4. Resident 64 had a bottle of Tylenol in the medication cart, and it lacked a label. 5. Resident 49 had an insulin pen lantus in the medication cart dated [DATE]. It expired 28 days after opening. 6. […]

• No harm, potential for more than minimal, patternF880Mar 27, 2025

  A. Based on observations, interviews, and record reviews, the facility failed to ensure appropriate infection control measures were used during the administration of a nasal spray for a resident for 1 of 1 observation of a nasal spray administration (Resident 13). B. Based on observations, interviews, and record reviews, the facility failed to ensure consistent and effective infection control practices related to enhanced barrier precautions (EBP) to ensure staff and visitors were aware of who required EBP and that personal protective equipment (PPE) was readily accessible for 6 of 6 residents reviewed for EBP (Residents 44, 34, 41, 71, 15, and 46). Findings include: A. […]