Jeffrey & Susan Brudnick Center for Living

In the surveyor’s words

From the most serious findings on record at Jeffrey & Susan Brudnick Center for Living, in the surveyor’s own words.

• Actual harm, isolatedF689Feb 1, 2024

  Based on observations, record reviews, policy review and interviews, the facility failed to prevent a fall with major injury for 1 Resident (#43) out of a total sample of 34 residents. Specifically, the facility failed to complete the admission fall risk assessment and implement fall prevention interventions for a Resident with a history of recurrent falls and Traumatic Brain Injury, resulting in a fall with acute facial fractures. Findings include: Review of the facility policy titled, Fall Clinical Protocol, undated, indicated the following: *Fall assessments must be conducted by a licensed nurse on admission, after a fall, quarterly, and with a significant decline of functional status. […]

• No harm, potential for more than minimal, patternF656Jan 30, 2025

  Based on observation, record review and interview, the facility failed to develop and implement a person- centered comprehensive care plan for three Residents (#335, #29 and #18) out of a total sample of 30 residents. Specifically, 1. For Resident #335, the facility failed to develop orders or a care plan for the use of ACE wrap bandages. 2. For Resident #29, the facility failed to devlop a care plan for alcohol use disorder when a resident, with known history of alcohol use disorder was found with alcohol bottles in his/her room. 3. […]

• No harm, potential for more than minimal, patternF641Feb 1, 2024

  Based on interview and record review the facility failed to accurately code the Minimum Data Set (MDS) assessment for four Residents (#123, #52, #140, and #61) out of a total sample of 34 Residents. Findings include: 1a.) Resident #123 was admitted to the facility in July 2023 with diagnoses that included Parkinson's disease, dementia, and malnutrition. Review of Resident #123's Minimum Data Set (MDS), dated [DATE], failed to indicate a fall with major injury. Review of Resident #123's nursing progress note, dated 7/18/23, indicated he/she was transferred to the hospital on 7/17/23 after he/she reported an unwitnessed fall and an X-ray confirmed a right hip fracture. […]

• No harm, potential for more than minimal, patternF686Feb 1, 2024

  Based on observations, record reviews, policy reviews and interviews, the facility failed to follow recommendations for the treatment of pressure ulcers for three Residents (#65, #6, and #52) out of a total sample of 34 residents. Specifically, the facility 1) failed to follow a recommendation to offload a wound for Resident #65 and 2) failed to maintain the correct air mattress setting for two Residents #6 and #52. Findings include: Review of the facility policy titled Pressure Ulcer Prevention, not dated, indicated When in bed, every attempt should be made to float heels (keep heels off of the bed) by placing a pillow from knee to ankle or with other devices as recommended by clinical staff or the physician. […]

• No harm, potential for more than minimal, patternF759Feb 1, 2024

  Based on observations, records reviewed, policy review and interviews, the facility failed to ensure it was free of a medication error rate of five percent or greater when 2 of 4 nurses, made 6 errors in 28 opportunities, totaling a medication error rate of 21.43%. These errors impacted 2 Residents (Resident #291 and #114) out of 4 residents observed. Findings include: Review of the facility policy titled Administering Medications, not dated, indicated Medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. The individual administering medications must verify the resident's identity before giving the resident his/her medications using 2 identifiers. 1. […]