Continuing Care at Brooksby Village

In the surveyor’s words

From the most serious findings on record at Continuing Care at Brooksby Village, in the surveyor’s own words.

• Actual harm, patternF684Dec 23, 2024

  Based on observations, interviews, and record review, the facility failed to ensure its staff provided treatments in accordance with professional standards of practice for one Resident (#12) out of a total sample of 18 residents. Specifically, for Resident #12: 1. The facility failed to ensure a wound clinic appointment was re-scheduled to obtain new wound treatment interventions when requested by the Nurse Practitioner for a deteriorating right lower extremity wound, resulting in the wound continuing to deteriorate. 2. […]

• Actual harm, isolatedF656Jul 20, 2022

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Comprehensive Plan of Care (POC) indicated he/she required two or more staff members assistance with care needs, including incontinence care, the Facility failed to ensure staff implemented and followed interventions from his/her POC to have two or more staff members present to assist during care. On 7/02/22, Certified Nurse Aide (CNA) #1 provided incontinent care to Resident #1 unassisted by an another staff person, as CNA #1 rolled Resident #1 onto his/her side during care, he/she slid out of bed, and fell on to the floor landing between the bed and the wall. […]

• Actual harm, isolatedF689Jul 20, 2022

  Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who required two or more staff assistance for care needs, including incontinence care, the Facility failed to ensure he/she was provided with the required level of staff assistance to maintain his/her safety and prevent incident/accident resulting in injury. On 7/02/22, Certified Nurse Aide (CNA) #1 provided incontinence care to Resident #1 unassisted by a second staff person, as CNA #1 rolled Resident #1 onto his/her side, he/she slid out of bed and fell to the floor, landing between the bed and the wall. […]

• No harm, potential for more than minimal, widespreadF944Dec 23, 2024

  Based on review of the Facility Assessment, employee education record review, and interviews, the facility failed to implement mandatory training on Quality Assurance and Performance Improvement (QAPI) for 15 employees. Findings include: Review of the Facility Assessment, dated 11/1/24, failed to indicate mandatory QAPI training. Review of 15 employee education files for 5 certified nurse assistants (CNAs) and 10 licensed nurses indicated: - 0 out of 15 direct care employees had documentation they had completed QAPI training during their employment. During an interview on 12/23/24 at 9:03 A.M., the Administrator said the facility does not provide any QAPI training to employees.

• No harm, potential for more than minimal, patternF550Dec 23, 2024

  Based on observations, interviews, and record reviews, the facility failed to provide a dignified experience for Residents on one of two units. Specifically, the facility failed to ensure that staff did not speak a foreign language while in the presence of, and while providing care for, Residents on the Terrace unit. Findings include: Review of the facility policy, titled Resident Rights - Continuing Care, dated June 2023, indicated the following: - Residents have the right to be treated with respect and dignity. During the Resident group meeting on 12/19/24 at 1:30 P.M., three out of three primarily English-speaking Residents said that staff have spoken in a foreign language to each other in front of them. […]