Brooking Park

In the surveyor’s words

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

• Immediate jeopardy, isolatedF700Dec 4, 2024

  Based on interview and record review, the facility failed to assess one of four sampled residents (Resident #1) for risk of entrapment from a bed rail and failed to ensure the bed rail did not pose a risk of entrapment when staff installed bed rails with a low air loss mattress. The resident was at risk for a serious adverse outcome when staff failed to assess the use of bed rails with the addition of a new low air loss mattress. On [DATE] at 9:40 P.M., staff found the resident on the floor with his/her head stuck between the rail and the mattress. The resident's buttocks were on the floor, his/her neck was stuck between the rail and the mattress, and his/her face was blue. The resident expired at the hospital. […]

• No harm, potential for more than minimal, widespreadF812Jul 24, 2024

  Based on observation, interview, record review, and facility document and policy review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure: 1. open food items were labeled with a description of the food item and an open or expiration date; 2. food items were not stored beyond their use-by-dates and moldy onions were discarded; 3. dishware was allowed to airdry prior to use for meal service; 4. prepared foods were stored in a manner to prevent potential cross-contamination; and 5. […]

• No harm, potential for more than minimal, patternF585Dec 9, 2024

  Based on interview and record review, the facility failed to maintain an effective grievance process for residents and family members to voice grievances and to promptly resolve grievances for one resident (Resident #1). The facility failed to follow-up on concerns expressed at Resident Council meetings. In addition, the facility failed to identify a Grievance Official responsible for overseeing grievances in their policy. The failure has the potential to affect all residents. The census was 52 with 25 in certified beds. […]

• No harm, potential for more than minimal, patternF809Dec 9, 2024

  Based on observation, interview, and record review, the facility failed to ensure the residents were served meals in a timely manner, which included two sampled residents (Resident #1 and Resident #2). The sample was eight. The census was 52 with 25 in certified beds. 1. Review of the facility's menus labeled Bistro 307 showed: -Breakfast is served at 7:30 A.M. through 9:00 A.M.; -Lunch is served at 11:30 A.M. through 1:00 P.M.; -Dinner is served at 4:30 P.M. through 6:30 P.M. 2. […]

• No harm, potential for more than minimal, patternF880Jul 24, 2024

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure enhanced barrier precautions (EBP) were implemented for 3 (Resident #17, #21, and #22) of 3 residents reviewed for EBP and failed to ensure respiratory equipment was stored in a manner to decrease risk of infection for 3 (Resident #22, #228, and #230) of 3 residents reviewed for respiratory care. The facility also failed to follow their infection control policy when staff failed to complete a two step and the annual one step of the employee tuberculosis (TB, a potentially serious infectious bacterial disease that mainly affects the lungs) screening tests in a timely manner for a total of seven employees. The census was 100 with 69 in certified beds. […]