Peak Resources - Brookshire, Inc

In the surveyor’s words

From the most serious findings on record at Peak Resources - Brookshire, Inc, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Apr 7, 2022

  Based on observations, record review and staff interviews the facility failed to maintain water temperature during the wash cycle of the dishwasher according to manufacturer's instructions, failed to discard expired food and beverages, failed to cover, label, and date opened foods, failed to do hand hygiene and glove use between food preparation and sweeping the floor, and failed to keep ice machine clean. The findings included: During the initial tour of the main kitchen on [DATE] at 9:35 AM to 10:20 AM revealed the following: 1. On [DATE] at 9:35 AM it was observed that the water temperature during the wash cycle of the dishwasher that used chemical sanitation was 100 degrees Fahrenheit during the wash cycle. The machine is a single rack low temperature chemical dishwasher. […]

• No harm, potential for more than minimal, patternF641Oct 27, 2023

  Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) for 4 of 31 residents reviewed (Resident #20, Resident #21, Resident #36 and Resident #3). Findings included: 1. The facility's Pre-Admission Screening and Resident Review (PASRR) query form dated 4/20/2022 indicated Resident #20 had a Level II PASRR determination due to mental illness. Resident #20 had been admitted on [DATE]. His diagnoses included Schizoaffective disorder Bipolar type. The most recent Annual MDS assessment dated [DATE] did not indicate Resident #20 was currently considered by the state Level II PASRR process to have a serious mental illness. An interview with the Social Worker (SW) and MDS Nurse #1 was conducted on 10/25/23 at 12:55 PM. […]

• No harm, potential for more than minimal, patternF804Oct 27, 2023

  Based on observations, record reviews and interviews with residents and staff the facility failed to serve food that was palatable and at temperatures acceptable to 4 of 5 residents review for cold foods. (Resident #42, Resident #67, Resident #174, and Resident #177) This practice had the potential to affect other residents. Findings included: a. Resident #42 was admitted to the facility on [DATE] and readmitted on [DATE]. A review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #42 was cognitively intact and independent with eating after assistance with meal set up. […]

• No harm, potential for more than minimal, patternF761Apr 7, 2022

  Based observation and staff interview, the facility failed to discard expired medications in 1 of 1 medication room and failed to date and label medication in 1 of 2 medication carts on the 100 hall reviewed for medication storage. Findings included: a. An observation of the medication room, on 4/07/22 at 9:32 AM revealed 2 unopened bottles of Vitamin E 90 mg (200 IU) tablet - expiration date 1/22 1 opened bottle of low dose aspirin tablet - expiration 4/21. During an interview on 04/07/22 at 09:35 AM with the Treatment Nurse regarding the medication room, she stated that all nurses were responsible for checking the medication room for expired medication. The Medical Records Clerk ordered supplies and removed the expired medication. […]

• No harm, potential for more than minimal, patternF809Apr 7, 2022

  Based on resident and staff interviews the facility failed to offer or deliver bedtime snacks to 2 (Resident # 33 and Resident # 40) of 2 residents reviewed for the delivery of snacks. Findings included: A. According to the Minimum Data Set (MDS) for Resident # 33 she was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15. On 04/04/22 at 11:26 AM an interview was conducted with Resident # 33. She stated that bedtime snacks were not delivered or offered. During a second interview with Resident # 33 on 04/06/22 at 09:47 AM she stated that she never received, and she was not offered a snack on 04-05-2022. B. According to the Minimum Data Set (MDS) for Resident # 40 she was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15. […]