Brooken Hill Health And Rehab, Llc

Number of residents sampled: Number of residents cited: Based on observation, record review and interview, the facility failed to ensure shaving and nail care services were regularly provided to promote good personal hygiene and grooming for one (Resident #91) resident reviewed for shaving and one (Resident #107) resident reviewed for nail care services. The findings include: 1. On 04/21/2026 at 9:14 AM, Resident #91 was observed lying in bed with eyes closed and both arms were above the bed linen, exposing both the resident's arms and hands. There was nothing covering either of the residents' arms. The fingernails on both of the resident's hands extended over the tips of the fingers. On 04/22/2026 at 9:04 AM. Resident #91 was observed sitting up in a low chair in the common area located between halls 800 and 900. Resident #91 was holding a carton of a supplemental drink in the right hand. The fingernails on Resident #91's right hand extending over the tip of the fingers. Resident #91's left hand was not visible at this time. Resident #91's arms were exposed and there was nothing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: Number of residents cited: Based on observations, record review, and interviews, the facility failed to ensure a resident with self-administration rights had the ability to follow instructions to ensure medications were not left at the bedside on three different observations for one (Resident #125) of one resident with self-administration rights reviewed. The findings include: Review of Resident #125's Medical Diagnosis report revealed the resident had diagnoses which included respiratory failure, heart failure, and type 2 diabetes. Review of an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/20/2026 indicated the status of the assessment to be in progress. The MDS indicated Resident #125 was admitted to the facility on [DATE] and did not indicate the resident was on oxygen therapy. Review of Resident #125's Order Summary revealed an order for a beta2-agonist inhaler to be taken three times a day for acute respiratory failure with a start date of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Number of residents sampled: Number of residents cited: Based on record review, interview, and facility policy review, the facility failed to report an allegation of mistreatment to the proper state agency for one (Resident #74) of two residents reviewed for an allegation of abuse. The findings include: A review of the abuse policy, dated as revised 10/18/2022, revealed the facility will endeavor to protect residents from maltreatment, which means adult abuse, sexual abuse, neglect, misappropriation of resident property, and exploitation of residents. The abuse policy indicated that all facility personnel, including all employees and any physician, the owner and Administrator, must immediately report all incidents of alleged, witnessed or suspected resident maltreatment, including abuse to the Administrator, or Administrator's designee, who will report events as required by State law or regulation. The abuse policy indicated all alleged violations will be reported immediately, but not later than two hours after the allegation is made, if abuse if involved or result in serious bodily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Number of residents sampled: Number of residents cited: Based on record review, interview, and facility policy review, the facility failed to maintain evidence an allegation of mistreatment was thoroughly investigated for one (Resident #74) two residents reviewed for an allegation of abuse. The findings are: A review of the abuse policy, dated as revised 10/18/2022, revealed the facility will endeavor to protect residents from maltreatment, which means adult abuse, sexual abuse, neglect, misappropriation of resident property, and exploitation of residents. The abuse policy revealed the Administrator or Administrative Designee will conduct an immediate investigation of all alleged, witnessed or suspected resident maltreatment, including abuse. The abuse policy indicated the investigator should consider interviews with the facility employees, victim resident, other residents, family members and other persons who may have knowledge of the incident. On 04/20/2026 at 2:37 PM, Resident #74 was interviewed and when asked if any staff had been physically abusive towards the resident,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Number of residents sampled: Number of residents cited: Based on record review and interview, the facility failed to ensure a significant change Minimum Data Set (MDS) was completed within 14 days from the effective date of the hospice service election for one (Resident #91) of two residents reviewed for Hospice services. The findings include: Review of the Centers for Medicare and Medicaid Services' (CMS's) Resident Assessment Instrument (RAI) Version 3.0 Manual, version 1.20.1 and dated October 2025, revealed a Significant Change in Status Assessment (SCSA) is required when a terminally ill resident enrolls in a hospice program, or changes hospice providers and remains a resident at the nursing home. The Assessment Reference Date (ARD) must be within 14 days from the effective date of the hospice service election. On 04/23/2026at 9:28 AM, Certified Nursing Assistant #14 was interviewed and stated Resident #91's baths were provided by the Hospice aids and stated she thought the Hospice aid came to the facility three days a week. A review of the Physician's Orders for Resident #91…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: Number of residents cited: Based on observations, interviews, record review, and facility document review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan reflecting a communication deficit of a nonverbal resident one (Resident #99) of one reviewed for comprehensive care planning. The findings include: During concurrent observation and interview on 04/21/2026 at 2:14 PM, Resident #99 was in their room sitting in a wheelchair with two family members present. Resident #99 was unable to move the right side of their body, including face/mouth due to a stroke and was nonverbal. Resident #99 did move the left hand to indicate numbers. The family members stated, no one at the facility knew sign language and they had never seen a staff member use a communication board or anything like that, but [staff] did ask yes/no questions. A review of Nursing Admit/Readmit/Quarterly Assessment dated 03/04/2026, indicated nonverbal Resident #99 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Number of residents sampled: Number of residents cited: Based on observations, record reviews and interviews, the facility failed to utilize appropriate equipment during resident transfers for one (Resident #36) of three residents reviewed for accidents to ensure residents were not put at risk for injury. Specifically, staff transferred a resident without using a gait belt resulting in a fall with knee abrasion. The findings include: Review of a Medical Diagnosis Report revealed Resident #36 had diagnoses which included left lower leg blood clot, stage 4 kidney disease and type 2 diabetes. Review of Resident #36's admission Minimum Data Set (MDS) with an Assessment Reference Date of 02/02/2026 revealed a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS also indicated Resident #36 had one fall in the last 2-6 months. Review of an unwitnessed Incident and Accident Report, dated 03/19/2026, Resident #36 slid out of a wheelchair while trying to pick a ring up from the floor. Resident #36 had no injuries. Review of witnessed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: Number of residents cited: Based on observations, record reviews and interviews, the facility failed to ensure scheduled orders for oxygen therapy were active before administering oxygen to a resident and failed to ensure respiratory care services in accordance with resident preferences to have humidified water for comfort, affecting one (Resident #125) of one resident reviewed for respiratory care. Specifically, Resident #125 was without humidified water for nasal comfort over three days, and on day two an empty humidified water bottle was dated 4/21/2026 when oxygen storage bag and tubing were replaced. The findings include: Review of a Medical Diagnosis report revealed Resident #125 had diagnoses which included respiratory failure, heart failure, and diabetes type II. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/20/2026 indicated the MDS was in progress. The MDS indicated Resident #125 was admitted to the facility on [DATE] but did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, facility policy review, it was determined the facility failed to obtain and implement physician orders to provide care for a post-operative surgical wound for one (Resident #2) of three residents reviewed for wound care quality. Resident #2 experienced wound dehiscence, rehospitalization, and emergency surgery. The findings include: A review of a facility undated document titled, Admission/Readmission/Transfer back from hospital heads up form, indicated ways to prepare the room, gather needed equipment, and gathering of specific resident history. No guidance was provided for physician contact or intake of orders. A review of a facility document titled, Dressing Change Using Aseptic Technique, dated 11/22/2016, indicated steps for gathering equipment and supplies as well as steps through the procedure. There was no mention of referring to Physician Orders for assessment or instructions of documentation of the process. A review of the Charge Nurse Job Description…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.