Brooke Knoll Village

Based on observations, interviews and record reviews, the facility failed to ensure residents had the right to privacy and dignity when staff failed to knock and announce themselves before entering the residents' room for 3 of 3 residents reviewed for dignity (Resident 25, 34, and 46), and for 1 of 1 resident council meeting (Residents 9, 20, 48, 11, and 43). Findings include: 1. During an interview on 3/24/25 at 10:25 a.m. with Resident 25, an unknown staff member opened the door without knocking and entered the room. The staff member indicated she was looking for Resident 25's roommate and then left abruptly. Resident 25 indicated a lot of staff members did not knock before they entered the room or the bathroom. Staff would often make demeaning comments about the smell when she had a bowl movement. Resident 25 indicated when staff did not knock before coming into the room or bathroom it made her feel disrespected and undignified.2. During a random observation on 3/26/25 at 8:51 a.m., Certified Nursing Aide (CNA) 12 and another unidentified CNA rolled a hoyer lift to Resident 34's…

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 observation and interview, the facility failed to date medications when opened and label over the counter medications for 3 of 6 medication carts reviewed (Residents 34, 47, 5, 64, 49, 11, 44, and 59). Findings include: 1. Resident 34 had an insulin pen lispro in the cart dated [DATE]. It expired 28 days after opening. 2. Resident 47 had latanoprost eye drops in the medication cart with no date to indicate when they were open for 2 of 2 bottles observed. 3. Resident 5 had a bottle of nasal deep-sea spray in the cart with no date to indicate when it was opened. 4. Resident 64 had a bottle of Tylenol in the medication cart, and it lacked a label. 5. Resident 49 had an insulin pen lantus in the medication cart dated [DATE]. It expired 28 days after opening. 6. Resident 11 had a bottle of Tylenol in the medication cart with no label on the bottle. She had a nasal spray, nanogel, in the cart with no date to indicate when it was opened. 7. Resident 44 had a bottle of fish oil with no label on the bottle. 8.…

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.

A. Based on observations, interviews, and record reviews, the facility failed to ensure appropriate infection control measures were used during the administration of a nasal spray for a resident for 1 of 1 observation of a nasal spray administration (Resident 13). B. Based on observations, interviews, and record reviews, the facility failed to ensure consistent and effective infection control practices related to enhanced barrier precautions (EBP) to ensure staff and visitors were aware of who required EBP and that personal protective equipment (PPE) was readily accessible for 6 of 6 residents reviewed for EBP (Residents 44, 34, 41, 71, 15, and 46). Findings include: A. During a medication administration observation on 3/27/25 at 8:30 a.m., Licensed Practical Nurse (LPN) 13 was observed as she prepared a nasal spray for Resident 6. LPN 13 set and administered the resident's oral medications, then returned to the cart to prepare the resident's nasal spray. LPN 13 proceeded to administer the residents nasal spray without performing hand hygiene or donning gloves. After administering…

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.

Based on observation, interview and record review, the facility failed to ensure the resident had the right to chose when he received routine lab draws that honored his preference not to be woken up too early for 1 of 1 residents reviewed for choices. Findings include: During an interview on 3/24/25 at 2:11 p.m., Resident 47 indicated, he was doing ok except he was tired of being woken up too early to keep getting blood draws. He indicated last time he woke up around 2:00 a.m. with a needle in his arm, it had startled him and made him mad. When they came that early to get his blood, they turned on the lights, jostle him in bed, stuck him and drew the blood, then he had a hard time falling back asleep. Resident 47 indicated he did not understand why he had to keep getting so much lab work done, and he wished they would do it later in the day. During a follow up interview on 3/27/25 at 8:48 a.m., Resident 47 indicated he did not understand, why they keep getting me up so D--- early for all this blood work. He couldn't go back to sleep then felt grumpy throughout the day. He indicated…

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.

Based on record review and interviews, the facility failed to initiate a new PASARR (Preadmission Screening and Resident Review)screening after a new mental health diagnosis was added to the diagnosis listing for 1 of 1 resident reviewed for PASARR (Resident 3). Findings include: On 3/27/25 at 8:56 a.m., a record review was completed for Resident 3. She had the following diagnoses which included but were not limited to bi-polar , dementia, essential hypertension, chronic kidney disease, and major depressive disorder. Resident 3 had a level I (A Level 1 Screening involves completion of an evaluation to determine if an individual has, or is suspected of having, a PASRR condition, i.e., serious mental illness (SMI), intellectual disability (ID), developmental disability (DD), or related condition (RC) completed on 1/24/25. The diagnosis listed on her level I was major depression. On 4/15/24, Resident 3 had a new diagnosis of bi-polar added. Resident 3's record lacked documentation that a new PASRR screening was completed to determine if a level II was required. During an interview on…

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 record review and interview, the facility failed to ensure a comprehensive discharge plan was in place and implemented for 1 of 2 closed record reviewed (Resident 80). Findings include: On 3/26/25 at 8:46 a.m., Resident 80's closed record was reviewed. She had been a short-term resident who completed a rehabilitation stay from 12/17/24 - 12/29/24 for aftercare following a joint replacement surgery. Resident 80 had a comprehensive care plan, dated 12/18/24, which indicated her desire to discharge home, but her goal was TBD (to be determined). Interventions for this plan of care were not person centered and adaptive equipment needed was left blank as well as home services needed was left blank. A Discharge summary, dated [DATE], was reviewed. The recapitulation of the resident's stay was left blank. A summary at the time of her discharge was left blank. Her discharge plan of care indicated, discharge hom and proceed with home health for nursing, physical and occupational therapy and home health aide. The…

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.

Based on observation, record review, and interview, the facility failed to prevent the potential for accidents related to medications at bedside for 2 of 4 residents reviewed for accidents (Residents 60 and 33). Findings include: 1. On 3/26/25 at 1:30 p.m., a record review was completed for Resident 60. He had the following diagnoses which included but not limited to hypertension, arthritis, weakness, and anxiety. On 3/24/25 at 10:12 a.m., Resident 60 was sitting in his wheelchair with his back at the door. Behind him on a table was a cup of pills. The color of the pills was white, orange, and red. There were approximately 8 pills in the cup. On 3/25/25 at 1:58 p.m., the Regulatory Consultant indicated the Qualified Medication Assistant (QMA) was instructed not to leave Resident 60's medications at bedside unattended. On 3/27/25 at 10:21 a.m., the Director of Nursing (DON) indicated he was now allowed to have his medication at bedside.2. During a medication pass on 3/27/25 at 8:20 a.m. Resident 33 indicated to Licensed Practical Nurse (LPN) 13, there was a pill on the floor next to…

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 observation, interview and record review, the facility failed to ensure residents with significant past trauma and/or post-traumic stress disorder (PTSD) received personalized care to address and avoid triggers for 2 of 2 residents reviewed for trauma informed care (Residents 25 and 65). Findings include: 1. During an interview on 3/24/25 at 10:25 a.m., Resident 25 indicated she regularly stayed up late at night because she couldn't shut her mind off and had trouble going to sleep and staying asleep. On 3/25/25 at 1:35 p.m., Resident 25's medical record was reviewed. She was a long-term care resident whose diagnoses included, but were not limited to Multiple Sclerosis (a chronic, autoimmune disease that affects the brain and spinal cord) and Major Depressive Disorder. A progress note, dated 1/1/2025 at 4:52 a.m., indicated Resident 25 was up in her wheelchair awake. When the nurse asked the resident if she had slept any throughout the night the Resident indicated she had not because she had too much on…

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.

Based on record review and interview, the facility failed to follow up with pharmacy recommendations in a timely manner for 1 of 5 residents reviewed (Resident 69). Findings include: On 3/26/25 at 1:02 p.m., a record review was completed for Resident 69. He had the following diagnoses which included but were not limited to encounter for palliative care, hypertension, sleep apnea, and pain. He had a pharmacy recommendation on 2/5/25 for a reduction in the amount of aspirin he was receiving. The physician did not respond until 2/12/24, 7 days later. Resident 69 had a pharmacy recommendation on 2/5/25 for a reduction gabapentin and the current dosage. The physician did not respond until 2/12/25. On 3/26/25 at 1:32 p.m., the Regulatory Consultant indicated the facility's policy indicated they have 3 days to get pharmacy recommendations completed. On 3/27/25 at 10:09 a.m., The Director of Nursing (DON) indicated they send the recommendation to the physician and if there was no response in 3 days, she sent it again. She flagged the recommendations and when the physician responded, she…

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 interview and record review, the facility failed to ensure a resident's wheelchair wheels were engaged into the facility van wheelchair-locks properly for 1 of 3 residents reviewed for accidents (Resident B). The deficient practice was corrected on 2/22/24, prior to the start of the survey, and was therefore Past Noncompliance. Finding includes: A confidential interview during the survey indicated on 2/20/24 Resident B was being transported in the facility van while seated in her wheelchair. Resident B's wheelchair was not strapped into the van properly. The wheelchair and resident tipped over and the resident hit her head. During an interview, on 3/8/24 at 2:00 p.m., the Corporate Consultant (CC) indicated Resident B had an accident while riding in the facility van. The van made a sudden stop that caused the resident and the wheelchair to tip backwards. The resident her hit head on the wall/floor of the van. A facility nurse went to the van and assessed the resident. The resident had a bump on the back…

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.

Based on observation, interview and record review, the facility failed to ensure call lights were placed within reach for 4 of 4 residents randomly observed for call light placement (Residents 13, 31, 52 and 71). Findings include: 1. On 1/19/24 at 11:38 a.m., Resident 13 was observed during a hall-tray lunch meal service. She was seated in her wheelchair at the foot of her bed. Her bed was neatly made but her call light was observed draped on top of the mattress near her pillow. The call light was out of sight and out of reach. During an interview on 1/19/24 at 11:40 a.m., Resident 13 indicated she did not like the meal because it was fried fish, and she did not like any fish. When asked if she could call and ask for an alternative meal, Resident 13 indicated she thought she had a call button, but did not know where it was, so not to bother with it. On 1/19/24 at 11:50 a.m., CNA 8 and an unidentified Dietary aide returned with a new lunch tray. Resident 13 was provided with a fresh garden salad and a peanut butter and jelly sandwich. The staff helped her set up her tray and exited…

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.

Based on observation and interview, the facility failed to ensure that expired medications were replaced and failed to ensure a refrigerated medication was stored in the refrigerator for 5 of 6 residents reviewed for medication storage (Residents 5, 38, 58, 68, and 243). Findings include: 1. During an observation on 1/24/23 at 10:02 a.m., the 400-hall medication cart was observed. The cart contained erythromycin eye ointment lacked a date to indicate when it was opened and a NovoLog insulin pen that was dated 12/19/23 was expired, belonging to Resident 68. 2. During an observation on 1/24/23 at 10:15 a.m., the front 300 hall medication cart was observed. The cart contained several medications that were undated when they were opened. a. Resident 5 had saline nasal (sodium chloride) aerosol spray 0.65% (use for thick or crusty mucus) with no date added to indicate when it was opened. b. Resident 58 had fluticasone proprionate 50mcg/actuation (a medication used to treat sneezing, itching or runny nose and other symptoms caused by hay fever) with no date to indicate when opened.…

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.

Based on observation and interview, the facility failed to accurately code the MDS (Minimum Data Set) for 1 of 2 residents reviewed for PASARR (Pre-Assessment Screening and Resident Review) for 1 of 2 residents reviewed for accuracy (Resident 39). Findings include: During a comprehensive record review on 1/29/24 at 12:36 p.m. Resident 39 had the following diagnoses which included but were not limited to major depressive disorder, anxiety disorder, unspecified dementia with behavioral disturbance, schizoaffective disorder, delirium, and mood disorder. Resident had a Level II evaluation to identify the specialized needs of individuals with mental illness, intellectual or developmental disability ID/DD, or both (MI/ID/DD) related to her diagnoses. It was determined on 7/6/2021 that she required level II services. She had a MDS completed on 4/25/34. The question, Is resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The answer was no indicating resident did not require a level II. During…

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 observation, interview, and record review the facility failed to ensure a resident's toenails were cut to prevent discomfort for 1 of 1 resident reviewed for activities of daily living care (Resident 15). Findings include: On 1/18/24 at 11:30 a.m., Resident 15 indicated she could not see the podiatrist (foot doctor) to get her toenails cut. She had diabetes and needed his care. On 1/22/24 at 11:08 a.m., an observation of Resident 15's toes showed very long, clean toenails. She indicated her daughter had been cutting them when the podiatrist did not see her. She had been in the facility for 4 and a half months. The podiatrist had been here three times and did not see her. She preferred the podiatrist to do her toenails because she was diabetic (blood sugar disorder) and did not want an injury on her foot. The facility had kept telling her she was on the list, but she had not seen him yet. On 1/22/24 at 2:28 p.m., the Infection Preventionist (IP) provided the podiatrist's resident list for the 8/14/23,…

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.

Based on observation, interview, and record review, the facility failed to ensure resident's equipment was maintained and free from the potential for accidents for 1 of 5 residents reviewed for accidents (Resident 33), and failed to ensure medications were not left at bedside for 1 of 5 residents reviewed for accidents (Resident 21). Findings include: 1. On 1/18/24 at 11:07 a.m., Resident 33's bed was initially observed. She had two, half siderails installed to her bed. The bedrail on the right side of the bed was observed to have fallen to the side, and when manipulated was observed to be loose and unsteady. The loose bedrail created a large gap between the mattress and rail. At that time, Resident 33 was seated in her wheelchair beside her bed and the plastic/rubber protective endcap of the wheelchair brake extender was observed to be missing so that the blunt metal end was level with her armrest. During an interview on 1/18/24 at 11:07 a.m., Resident 33 indicated her bedrail had been like that for some time, but she was still able to use it to get herself in and out of bed. The…

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.

Based on observation, record review, and interview, the facility failed to date feeding and water bags for 1 of 2 residents reviewed for feeding tubes (Resident 78). Findings include: During an observation on 1/18/24 at 10:57 a.m., Resident 78 was observed sitting in his wheelchair next to his bed. He had a bag of Isosource 1.5 with formula inside the bag and a bag with clear fluids hanging on a pole behind him. The feeding was disconnected from the resident. The formula was dated, and the clear fluid was not dated. During an observation on 1/19/24 at 10:24 a.m., Resident 78 was sitting up in his wheelchair. He had a bag of Isosource 1.5, with formula in it and a bag of clear fluid. Both bags lacked a date. On 1/19/24 at 2:15 p.m., Resident 78 had a bag of Isosource and a bag of clear fluid with no date on them and disconnected from the resident. A comprehensive record review was completed on 1/23/24 at 11:05 a.m. He had the following diagnoses which included but were not limited to respiratory failure, obstructive sleep apnea, malignant neoplasm, weakness, heart failure and type 2…

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.

Based on observation and interview, the facility failed to exchange oxygen equipment for a resident who received oxygen therapy for 1 of 4 residents (Resident 37). Findings include: During an observation on 1/18/24 at 10:55 a.m., Resident 37 was sitting up in his wheelchair next to his bed. He was wearing oxygen per nasal cannula. He had an oxygen bag, tubing, and humidified water attached to a wall unit of oxygen. The tubing, humidified water, and bag were dated 12/23/23. During an observation on 1/18/24 at 2:15 p.m., Resident 37 was sitting up in his wheelchair in his room. An oxygen bag with tubing inside and humidified water attached to a wall unit were dated 12/23/23. During an observation on 1/19/24 at 10:00 a.m., Resident 37 was sitting in his wheelchair in his room. He had an oxygen bag with tubing attached to an oxygen wall unit, along with humidified water dated 12/23/23. During an observation on 1/19/24 at 2:00 p.m., Resident 37 was sitting up in his wheelchair in his room. A wall unit of oxygen had tubing connected to it with humidified water. The tubing was placed…

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 observation, interview, and record review, the facility failed to ensure culturally appropriate and person-centered services, routine/preferences, and activities were available and/or implemented for a resident who spoke a different language for 1 of 1 residents reviewed for culturally competent care (Resident 71). Findings include: On 1/18/24 at 10:23 a.m., Resident 71 was initially observed. He was seated in a specialized high-back wheelchair (WC) in his room near the foot of his bed. He did not speak English, but there was a 3-ring binder observed on his dresser top. The binder indicated Resident 71 spoke [NAME] and included several pages of clip art pictures with [NAME] words. Most of the pages were tattered, folded, ripped or scribbled on. There were some words spelled phonetically in English but without indication of what the words were. Resident 71 was observed to have long hair pulled back into a ponytail, and a beard with long hair that came to a point at the top of his stomach. On 1/18/24 at…

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.

Based on observation, interview, and record review, the facility failed to ensure hand washing was completed according to policy for 2 of 4 residents (Residents 1 and 51). Finding include: On 1/18/24 at 11:55 a.m., Certified Nursing Aide (CNA) 19 was observed to pick up Resident 1's paper lunch ticket from the floor. Without hand washing or gelling her hands, she assisted Resident 1 and Resident 51 with eating. She started with her left hand, providing a bite of food to Resident 51. Then, provided a drink with her left hand and a bite with her right hand for Resident 1. She went back to Resident 51 and wiped her mouth and provided a drink and several bites of food with both her right and left hands. A current policy, titled, Handwashing/Hand Hygiene, dated 10/2014, was provided by the Infection Preventionist (IP), on 1/24/24 at 11:53 a.m. A review of the policy indicated, .Hand hygiene is the single most important measure for preventing the spread of infection .The hand hygiene guidelines are part of an overall CDC [Centers for Disease Prevention and Control] strategy to reduce…

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.