Complete Care at Brackenville LLC

In the surveyor’s words

From the most serious findings on record at Complete Care at Brackenville LLC, in the surveyor’s own words.

• Actual harm, isolatedF689Feb 2, 2024

  Based on interview, record review, and review of facility policy, the facility failed to ensure that supervision to prevent accidents for one Resident (R) 297 out of four sampled residents reviewed for accidents. This failure caused actual harm, when R297 sustained a subdural hematoma after a fall when Certified Nursing Assistant (CNA)1 left the resident sitting on the bedside, unattended, while gathering supplies for the resident's personal care. Findings include: Review of a policy provided by the facility titled Fall Prevention Program, dated 09/05/23 indicated .Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.The facility utilizes a standardized risk assessment for… […]

• Actual harm, isolatedF686Jul 25, 2022

  Based on interview and record review, it was determined that for two (R57 and R352) out of five sampled residents reviewed for pressure ulcer (PU), the facility failed to ensure PU care, treatment and services, consistent with professional standards of practice, were provided to the residents. For R352, a newly admitted resident who was at risk for developing PUs, the facility failed to ensure that R352 received care to prevent a new left heel PU from developing. R352's left heel PU was identified on 6/25/21 by F1 (R352's POA) and subsequently worsened, which required R352 to be evaluated in the emergency room (ER). R352 was admitted to the hospital and diagnosed with a left heel Deep Tissue Injury (DTI), resulting in harm. […]

• Actual harm, isolatedF689Jul 25, 2022

  Based on interviews, record review and review of facility documentation as indicated, it was determined that for one (R18) out of four residents sampled for accidents, the facility failed to ensure that R18, a dependent resident, was transferred using a hoyer lift with the assistance of two staff members on 8/19/21 as per her plan of care and the facility's hoyer lift policy and procedure. As a result of this incident, R18 was diagnosed with a femur fracture on 8/21/21, resulting in harm to the resident. In response to this incident, the facility implemented corrective actions. […]

• No harm, potential for more than minimal, widespreadF880Jul 25, 2022

  Based on observation and interview, it was determined that for two (R47 and R196) the facility failed to ensure adherence to infection control practices for glucometer use and insulin administration. Additionally, the facility failed to ensure the laundry room adhered to standards of practice to prevent infection. Findings include: The facility policy on hand hygiene, last revised 5/2021, indicated, If hands are not visibly soiled, use an alcohol based hand rub for routinely decontaminating hands before putting on clean gloves, after contact with residents skin, after contact with medical equipment, after removing gloves. […]

• No harm, potential for more than minimal, patternF610Mar 5, 2026

  Based on interview, record review, and policy review, the facility failed to thoroughly investigate allegations of abuse for four residents (Resident (R) 59, R88, R97, and R106) out of nine residents reviewed for abuse in a total sample of 40. This failure placed residents at risk of further abuse and a diminished quality of life.Findings include:1. Review of the admission Record, located in the Profile tab of the electronic medical record (EMR), revealed that R59 was admitted to the facility on [DATE] with diagnoses that included hemiplegia/hemiparesis (paralysis on one side of the body) following a cerebral infarct (stroke) and major depressive disorder.Review of the quarterly Minimum Data Set (MDS), located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 02/14/26,… […]