Brookshire Post Acute

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Oct 16, 2025

  Based on observations, record review and interviews, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for one (#10) of five residents out of 10 sample residents. Resident #1, age less than 65, required total assistance with bathing, was non-verbal and was unable to move his arms and legs. On 10/10/25 at 3:55 p.m. certified nurse aide (CNA) #1 requested a nurse to look at Resident #1's skin in the Summit shower room. CNA #1 stated she was using a washcloth and the resident's skin flaked off. The washcloth was noted to be light brown in color and peeled skin was observed on the shower floor. […]

• Immediate jeopardy, isolatedF600Sep 29, 2022

  Based on record review, observations, and interviews, the facility failed to create an environment that protected eight of 21 residents reviewed (#20, #32, #42, #12, #33, #45, #37 and #55) from abuse. RESIDENT TO RESIDENT SEXUAL ABUSE Resident #20, with moderate cognitive loss, exhibited inappropriate sexual behavior toward three residents (#42, #12, and #32), all of whom were severely cognitively impaired. Resident #42 was touched inappropriately on her breast on 7/14/22, Resident #12 was touched inappropriately on her breast on 8/29/22, and Resident #32 was touched inappropriately on her breast on 9/26/22, during the survey. […]

• Actual harm, isolatedF600Oct 12, 2023

  Based on record review and interviews, the facility failed to ensure one (#3) of two residents reviewed for abuse out of seven sample residents was free from resident-to-resident abuse. Residents #3 and #6, both severely cognitively impaired, were roommates as of 7/18/23, the date of Resident #3's admission to the facility. Resident #6 had a documented history of resident-to-resident physical and verbal aggression toward staff and other residents, including on 7/25/23 with Resident#3 for talking in his sleep. Despite staff knowing Resident #6's history of resident-to-resident altercations, including against Resident #3 on 7/25/23, staff failed to monitor and develop effective interventions to protect Resident #3 from Resident #6's further abuse. […]

• Actual harm, isolatedF686Oct 12, 2023

  Based on observations, record review, and interviews, the facility failed to provide the necessary treatment and services to prevent pressure injuries from occurring and worsening for one (#1) of three out of seven sample residents. Specifically, a staff interview revealed that on 10/5/23, she notified a nurse that Resident #1 had a small open area on her coccyx. The facility failed to ensure the resident's skin breakdown was comprehensively assessed and had a physician-ordered treatment in place until 10/9/23, four days after the pressure injury was identified. The wound physician's assessment on 10/9/23 revealed an unstageable pressure injury to the coccyx with obscured full-thickness skin and tissue loss. […]

• Actual harm, isolatedF688Oct 12, 2023

  Based on observations, record review, and interviews, the facility failed to ensure one (#1) of three out of seven residents with limited range of motion received appropriate treatment and services. Specifically, the facility failed to properly assess the resident's contracture and ensure the comprehensive care plan identified the contracture, and interventions were put into place to prevent the worsening of Resident #1's left elbow and left hand contracture. Although there were no measurements, staff and resident representative interviews revealed the resident's contracture had worsened. Findings include: I. Facility policy and procedure The Resident Mobility and Range of Motion policy and procedure, revised July 2017, was provided by the director of nursing (DON) on 10/18/23 at 8:00 a.m. […]