Brookwood Skilled Nursing and Therapy

In the surveyor’s words

From the most serious findings on record at Brookwood Skilled Nursing and Therapy, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Jan 7, 2025

  On 01/02/25 an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure Resident #2 who had insulin dependent type 2 diabetes mellitus with hypoglycemia was assessed, monitored, and provided medication for hypoglycemia as ordered by the physician and outlined in their care plan. Resident #2 was admitted to the facility on [DATE] with orders for routine insulin administration and insulin to be administered per sliding scale. Resident #2 also had orders for blood sugar to be checked via fingerstick twice a day and as needed for signs or symptoms of hypoglycemia and to give Glucagon (oral gel or IM) (glycogenolytic agent) if blood sugar was less than 70. […]

• Immediate jeopardy, isolatedF773Jan 7, 2025

  On [DATE] an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to promptly notify the physician of Resident #2's laboratory results which fell outside of clinical reference ranges and showed a deterioration in their condition. Resident #2 was admitted to the facility on [DATE] with diagnoses which included urinary tract infection (ESBL) and pneumonia and was receiving antibiotic therapy. Resident #2's admission lab results, dated [DATE], documented WBC 11.3 (Ref range 3XXX,d+[DATE].04) and Neutrophil # 7.7 (Ref range 1XXX,d+[DATE].13). The report was signed by the physician. Resident #2's follow-up lab results, dated [DATE], documented WBC 26.2 (Ref range 3XXX,d+[DATE].04) and Neutrophil # 19.7 (Ref range 1XXX,d+[DATE].13). […]

• Actual harm, isolatedF697Sep 17, 2025

  Based on observation, record review and interview, the facility failed to ensurea. residents received pain medication in a timely manner for 1 (#122) of 2 sampled residents reviewed for pain management. The prolonged wait time despite verbalizing increased pain to multiple staff resulted in harm for Resident #122 as evidenced by not wanting to complete ADL's due to pain; and,b. residents were consistently evaluated for the effectiveness of regularly scheduled pain medication for 1 (#101) of 2 sampled residents reviewed for pain management assessment and monitoring.The regional nurse consultant identified 42 residents received pain medication.Findings:1.On 09/16/25 at 5:55 a.m., Resident #122 was observed telling CNA #3 somebody get me some pain pills, my back is killing me. […]

• No harm, potential for more than minimal, widespreadF847Sep 17, 2025

  Based on record review and interview, the facility failed to ensure residents were provided with an option to not sign the arbitration agreement for 6 (#24, 31, 38, 46, 53, and #96) of 6 sampled residents reviewed for arbitration agreements.The administrator identified 114 residents had entered into a binding arbitration agreement.Findings:An undated document titled An Explanation to the Resident/Family, read in part, By signing our admission contract your electronic signature will be placed on the following forms, which you will receive copies of after signing. […]

• No harm, potential for more than minimal, patternF880Sep 17, 2025

  Based on observation, record review, and interview, the facility failed to ensure:a. EBP was followed during an incontinent care observation for 1 (#122) of 6 sampled residents reviewed for incontinent care; andb. ensure nasal cannulas were bagged when not in use and oxygen tubing was labeled with the date administered in order to prevent infections for 1 (#53) of 3 sampled residents reviewed for oxygen services.The regional nurse consultant identified 11 residents had O2 orders and 32 were on EBP. Findings: 1. On 09/16/25 at 8:08 a.m., CNA #1 and CNA #2 were observed to provide incontinent care for Resident #122. CNA #1 and #2 did not have on gowns during the provision of care. […]