Brookshire Healthcare Center

In the surveyor’s words

From the most serious findings on record at Brookshire Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF880Jan 6, 2021

  Based on observations, staff interviews, record reviews and review of the facility's policy entitled COVID-19 Education, Prevention & Response Guide, the facility failed to ensure all staff be screened for COVID-19 symptoms and/or exposures prior to entering one (1) of six (6) resident halls. This failure increased the risk of transmission of COVID-19 to residents and staff. The findings include: During the entrance conference on 01/05/21 at 8:45 AM with the Administrator and the Director of Nursing (DON), the DON stated that all staff are screened at the front entrance prior to reporting to their department for their work assignment. On 01/06/21 at 8:25 AM observations were made of staff entering the facility through the exit door off of the service hall. […]

• No harm, potential for more than minimal, isolatedF623Mar 17, 2022

  Based on interviews and record reviews, the facility failed to ensure a copy of Resident Identifier (RI) #30's transfer notice was provided to the ombudsman as soon as practicable after RI #30 was sent to the emergency room in 11/2021 due to medical concerns. This affected one of one resident reviewed for a transfer to the hospital. Findings include: A policy related to notifying the ombudsman of resident transfers/discharges was requested from the facility. On 03/17/2022 at 3:31 PM, Employee Identifier (EI) #2, the Director of Nursing (DON), indicated there was no facility policy on notifying the ombudsman of resident transfers/discharges. […]

• No harm, potential for more than minimal, isolatedF655Mar 17, 2022

  Based on interviews and record review, the facility failed to ensure a baseline care plan was developed within 48 hours of admission for Resident Identifier (RI) #89, one of nine sampled residents reviewed for a baseline care plan. Findings include: A review of the Admission Record for RI #89 indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of RI #89's Order Summary Report and Clinical Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] - Hospice services (order date of 02/17/2022) - Regular diet, dysphagia (difficulty swallowing foods) mechanical soft texture, with thin consistency liquids (start date of 02/17/2022); and - Wound care to the left hip (start date of 02/25/2022). […]

• No harm, potential for more than minimal, isolatedF656Mar 17, 2022

  Based on record review and interviews, the facility failed to ensure a comprehensive care plan was developed to address Resident Identifier (RI) #93's use of an antidepressant medication. This affected one of 24 sampled residents for whom care plans were reviewed. Findings include: RI #93 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #93's significant change Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/07/2021, indicated RI #93 received an antidepressant medication on seven out of seven days of the seven day assessment look-back period. […]

• No harm, potential for more than minimal, isolatedF657Mar 17, 2022

  Based on record review and interviews, the facility failed to ensure comprehensive care plans were developed and implemented for Resident Identifier (RI) #89 within seven days of the completion of RI #89's admission Minimum Data Set (MDS) assessment. This affected one of 24 sampled residents for whom care plans were reviewed. Findings include: A review of the Admission Record for RI #89 indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #89's admission MDS assessment was signed as completed by the Registered Nurse (RN) on 03/03/2022. On 03/14/2022 at 1:20 PM, RI #89's electronic medical record was reviewed. […]