Brookridge Retirement Community

In the surveyor’s words

From the most serious findings on record at Brookridge Retirement Community, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812May 9, 2024

  Based on observations and dietary staff interviews, the facility failed to ensure facial hair was covered during food preparation. This practice had the potential for cross-contamination of food served to residents. Findings included: During the initial tour of the kitchen on 5/6/24 at 10:00 a.m., the dietary staff were observed cleaning after the breakfast meal service and preparing food for the lunch meal. There were four dietary staff members preparing food in the preparation areas with exposed facial hair (ranging from approximately 1/2 inch to 3 inches in length). On 5/9/24 at 11:33 a.m. during the meal tray line service in the kitchen, seven dietary staff were observed with exposed/uncovered facial hair ranging from 1/2 inch to 3 inches in length. […]

• No harm, potential for more than minimal, widespreadF814May 9, 2024

  Based on observations and dietary staff interviews, the facility failed to ensure waste was contained in 1 of 1 trash compactor and had no opened areas with exposed trash, debris, and accessibility to animals. These practices had the potential to affect all residents. Findings included: On 5/6/24 at 10:54 a.m., during the observation of the facility's trash compactor accompanied by the Executive Chef and the Clinical Nutritionist, the opened chute area of the compactor consisted of multiple large white bags of trash and a live opossum. The Executive Chef immediately notified the Maintenance Director to remove the opossum. A follow-up observation of the trash compactor was conducted with the Executive Chef, Kitchen Manager, and the Clinical Nutritionist on 5/9/24 at 11:54 a.m. […]

• No harm, potential for more than minimal, isolatedF694Aug 1, 2025

  Based on observation, record review, and interviews with staff, resident, and the Physician the facility failed to change the dressing for the peripherally inserted central catheter (PICC) for intravenous antibiotic administration according to the order. This deficient practice affected 1 of 3 residents reviewed for intravenous access devices (Resident #63). The findings included: Resident #63's hospital Discharge summary dated [DATE] documented she had a PICC line placed on 7/14/25 into her right antecubital space (front of the elbow) and a clear dressing was placed. The resident was receiving antibiotics for endocarditis (infection of the heart tissue) and sepsis (infection of the blood) through the PICC line. […]

• No harm, potential for more than minimal, isolatedF656Jan 26, 2023

  Based on observations, staff interviews and record review, the facility failed to 1) follow the care plan to place floor mats next to the bedside for fall prevention for 1 of 4 residents (Resident #14) reviewed for falls, and 2) failed to implement a care plan for ileostomy care for 1 of 1 resident (Resident #10) reviewed for ileostomy bowel care. Findings included: 1) Resident #14 was admitted to the facility on [DATE] with diagnoses that included, in part, dementia, osteoporosis and repeated falls. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had severe cognitive impairment. She required extensive assistance with transfers and bed mobility. […]

• No harm, potential for more than minimal, isolatedF689Jan 26, 2023

  Based on observations, staff interviews and record review, the facility failed to provide intervention for fall prevention for 1 of 4 residents (Resident #14) reviewed for falls. Findings included: Resident #14 was admitted to the facility on [DATE] with diagnoses that included, in part, dementia, osteoporosis and repeated falls. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had severe cognitive impairment. She required extensive assistance with transfers and bed mobility. She was coded on the MDS as having one fall with no injury. The care plan, updated 11/24/22, included a focus area of risk for falls. […]