Brookshire Post Acute

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Administration Deficiencies

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

K-000 - INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).This survey was conducted on January 29, 2025 for compliance with the National Fire Protection Association, (NFPA 101) .. STANDARD is not met, as evidenced by observation and staff interviews during the survey; it was determined that the facility failed to arrange the exit access so that exits are readily accessible at all times per Life Safety Code 101 Section 19.2.2.2.4, 7.2.1.5.3.The Conference room door is equipped with a slide-action locking device, and two rele.. STANDARD is not met, as evidenced by: Based on record review and staff interviews during the survey, it was determined that the facility failed to maintain emergency power systems in accordance with section 19.2.9.1 of the Life Safety Code and the referenced 2010 NFPA 110, Section 8.3.8 Maintenance and Operational Testing. The facility .. STANDARD not met as evidenced by the following: During the review of the facility records confirm that the facility had the kitchen-hood-exhaust-system inspection as required by NFPA 96 (Chapter 11, Section 11.2.1). The facility was unable to provide documentation showing that the kitchen suppression system had been inspected and se.. STANDARD not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to maintain sprinkler protected hazardous areas in accordance with Life Safety Section 19.5.4.1, 9.5 and NFPA 82. 1. The laundry cute door servicing the basement and the first floor would not clos.. STANDARD not met as evidenced by: Based on observation and staff interview, it was determined that the facility failed to maintain all oxygen cylinders in storage as required by 2012 NFPA 99 Section 11.6.2.3. In the activity storage room, freestanding helium cylinders were not secured. These cylinders must be properly secured using chains.. STANDARD not met as evidenced by: It was determined through observation during the survey that the facility failed to provide flame retardant or coatings that comply with NFPAS 101 19.7.5.6, and NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.The corridor doors in the special needs unit are completely .. STANDARD not met, as evidenced by testing and staff interviews of the emergency lighting during the facility tour; it was determined the facility needed to maintain the battery-powered emergency lights per 7.9.3 and 19.2.9.1. The emergency backup lighting in the kitchen and generator housing did not illuminate when the test button .. STANDARD not met, as evidenced by the observation and staff interview during the survey. It was determined that the facility failed to maintain corridor doors per the Life Safety Code Section 19.3.6.3. 1. Door openings in the cross-corridor of the dining room do not latch and close completely into the doorframes, compromising the 20-minut.. STANDARD not met: Based on observation and staff interviews during the survey, it was determined that the facility needed to maintain the trans-filling of oxygen storage room ventilation per NFPA 99 - Health Care Facilities, 9.3.7.2 and NFPA 55 Compressed Gases and Cryogenic Fluids Code. The oxygen trans-filling room is not mechanically ventilat.. STANDARD not met: Based on record review, it was determined that the facility failed to maintain the automatic sprinkler system per National Fire Protection Association (NFPA) Standards 13 and 25. 1. During the survey, the record review revealed that the facility did not inspect and test the automatic sprinkler system semi-annually, as required b.. STANDARD was not met, by testing and staff interviews during the facility tour of the exit signage, it was determined that the facility failed to maintain the marking of means of egress per Life Safety 101 Section 7.10. Exit signs would not illuminate when the test button was pressed in the kitchen corridor.7.10.5.2* Continuous Illumination.7.10.5.2.1 ..

A recertification survey with complaints #CO36676, #CO37241, #CO37936, #CO38672, #CO38737 and Incident #37914 was completed on 1/12/25 to 1/16/25. Twelve deficiencies were cited. An Emergency Preparedness survey was conducted from 1/12/25 to 1/16/25. One deficiency was cited. Based on observation,record review and interviews, the facility failed to assist residents in obtaining routine or emergency dental services, as needed for one (#14) of two residents reviewed for dental services out of 30 sample re.. Based on observations and interviews the facility failed to store, prepare, distribute and serve food in a sanitary manner in the kitchen.Specifically, the facility failed to:-Ensure raw animal food was separated from ready to eat fo.. Based on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public.Specifically, the facility failed to ensure the laundry room was free fr.. Based on observations, record review and interviews, the facility failed to ensure one (#113) of three residents reviewed for assistance with activities of daily living (ADL) out of 30 sample residents received appropriate treatmen.. Based on observations, record review and interviews, the facility failed to ensure three (#32, #60, #50) of five residents reviewed for activities out of 30 sample residents received an ongoing program of activities designed to me.. Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for two .. Based on record review and interviews, the facility failed to develop a comprehensive care plan for two (#46 and #9) of six residents out of 30 sample residents for services to attain or maintain the resident' s highest practicable physica.. Based on record review and interviews, the facility failed to develop, implement and maintain an effective training program for staff based on the facility assessment and resident population for four of five certified nurse aides (CNA).. Based on record review and interviews, the facility failed to ensure a prompt resolution was provided to residents involved in group grievances. Specifically, the facility failed to provide a prompt and effective resolution for resident.. Based on record review and interviews, the facility failed to ensure one (#47) of five residents out of 30 sample residents had the right to be informed of and participate in their treatment,the right to be informed, in advance, of .. Based on record review and interviews, the facility failed to ensure that the medical record was complete and accurate in keeping with accepted standards of practice for one (#63) of four residents reviewed for medical record .. Based on record review and interviews, the facility failed to follow established requirements for testing the emergency preparedness plan.Specifically, the facility failed to complete a second community-based, facility-based f.. Based on record review and interviews, the facility failed to inform one (#60) of three residents reviewed for beneficiary notices and appeal rights out of 30 sample residents of changes in their services covered by Medicare in a..