Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brookfield Healthcare Center during CMS and state inspections, most recent first.
Vague orders for methocarbamol and Percocet led to repeated administration of the two medications at the same time or within an hour of each other for a resident with fractures, scoliosis, and chronic pain. The pharmacist, LPN, RN, and DON stated the order language was unclear because it did not specify a time frame, and MAR review showed 15 instances of close-together dosing.
Incomplete Care Plans for Medication Use and Missing Dentures: The facility failed to develop care plans for a resident receiving methocarbamol with specific interaction precautions and for another resident who had lost upper and lower dentures. Records showed both residents had significant medical and cognitive needs, and staff interviews confirmed the missing care plan elements were not in place for the medication monitoring and denture-related care needs.
Incomplete fall assessments and care plan updates after resident falls. A resident with reduced mobility, post-stroke weakness, and moderately impaired cognition had two falls, but staff did not complete all sections of the Fall Risk Eval after the first fall, did not develop a short-term care plan, did not complete a Fall Risk Eval after the second fall, and did not revise the existing fall care plan.
Oxygen therapy was not administered as ordered for two residents. One resident with CHF, asthma, and impaired cognition was observed receiving oxygen above the ordered rate, while another resident with chronic respiratory failure with hypoxia, CHF, and moderate cognitive impairment was observed receiving oxygen below the ordered continuous rate. An RN, LVN, and RN all stated the oxygen should be administered as ordered.
Inappropriate Meal Texture and Poor Palatability: A resident with DM and CHF was ordered a CCHO soft and bite sized diet, but was served a green pureed item at lunch instead of food cut into small pieces. The resident said the food looked like baby food, did not know what it was, and would not eat it after tasting it. The DS stated soft and bite sized diets should not be pureed, and the DON stated meals must match the prescribed diet and be palatable to support intake.
A resident with loose stools and suspected C. diff was placed on contact precautions, but the room sign did not specify soap-and-water handwashing. An LVN donned gown and gloves, provided care, then used ABHR after leaving the room before later washing with soap and water. The resident’s C. diff test later returned positive, and the IPN and DON stated the signage and hand hygiene method were not specific enough for spore precautions.
A resident with multiple health conditions and mobility impairments experienced a fall, but the subsequent fall risk reassessment did not document the recent fall or include key risk factors such as incontinence and wheelchair use. The incomplete evaluation resulted in a lower fall risk score, contrary to facility policy requiring accurate post-fall assessments.
A resident with significant mobility and cognitive impairments experienced a fall, but staff did not initiate a care plan or implement specific interventions to address the incident. Despite facility policy requiring a comprehensive, person-centered care plan after such events, no plan was developed to ensure the resident's safety.
A resident with asthma and COPD was administered both Advair Diskus and Serevent Diskus, leading to duplicate drug therapy with excessive salmeterol dosages. Nursing staff failed to consult drug references or pharmacists, resulting in 33 days of unnecessary medication. The oversight was identified during a review of medication records, revealing a lapse in adherence to facility policies.
A facility failed to obtain a complete informed consent for a resident receiving citalopram for major depressive disorder. The consent form lacked details on dosage, frequency, and behavioral manifestations, which are essential for informed decision-making. Interviews with the RN and DON highlighted the responsibility of licensed nurses to ensure residents and their Responsible Parties are fully informed about medication treatments.
The facility failed to ensure accurate MDS assessments for four residents, omitting diagnoses of depression and seizure disorder, and not recording significant weight loss. These inaccuracies could negatively impact the residents' care plans and necessary interventions.
The facility failed to develop timely, person-centered care plans for three residents, leading to deficiencies in their care. A resident with cancer did not have a care plan for her condition, another resident using a nicotine patch lacked a care plan for smoking cessation, and a third resident with an ileostomy had no care plan for its management. These oversights resulted in inadequate monitoring and support for the residents' health needs.
A resident with a history of falls and dementia experienced multiple falls, but the care plan was not updated to prevent future incidents. Despite the facility's policy requiring care plan revisions after falls, the plan remained unchanged, lacking new interventions. Interviews with staff confirmed the necessity of updating care plans to prevent further falls.
A resident with a history of falls and dementia experienced a fall, but the facility failed to conduct an interdisciplinary team (IDT) meeting to address the incident. Despite the requirement for such meetings to develop a care plan and prevent future falls, no IDT notes were found for the fall, delaying necessary interventions.
The facility failed to ensure safety for two residents by not using floor mats for a resident with seizures and not conducting an IDT review after another resident's fall. The first resident, with severe cognitive impairment, was observed without a required floor mat on one side of the bed, increasing the risk of injury during seizures. The second resident, with a history of falls and dementia, did not have an IDT meeting after a fall, delaying necessary interventions. These actions were against the facility's policies, potentially compromising resident safety.
The facility failed to ensure safe medication administration for four residents. A resident did not receive timely medication, and medications were left for self-administration. Another resident experienced delays due to an LPN running late, and a nurse documented administering medication they did not give. The DON confirmed these practices were unacceptable.
A resident was prescribed duplicate drug therapy with Serevent Diskus and Advair Diskus, both containing salmeterol, which was not identified during the Monthly Regimen Review. The facility's Consultant and Dispensing Pharmacists failed to recognize the duplicate therapy, contrary to the facility's policy requiring identification of such irregularities.
A facility failed to label opened inhalers with an open date for three residents, as required by manufacturers' guidelines. The medications, including Advair Diskus, Serevent Diskus, and Arnuity Ellipta, were found in the MedCart without the necessary labeling. An LVN and the DON confirmed the oversight, acknowledging the risk of using expired medications. The facility's policy and manufacturers' instructions emphasized the need for proper labeling to ensure medication effectiveness and resident safety.
A resident with severe cognitive impairment was prescribed Triamcinolone Acetonide Ointment for itching, but the facility failed to document the specific site of application. Staff interviews revealed a lack of assessment and communication, with the DON acknowledging the physician's order was incomplete, risking incorrect medication administration.
Vague pain medication orders led to methocarbamol and Percocet being given too close together
Penalty
Summary
Resident 19 was admitted with diagnoses including a displaced fracture of the greater trochanter of the left femur, a displaced fracture of the distal phalanx of the left index finger, scoliosis, and chronic pain syndrome. The MDS dated 10/23/2025 indicated moderately impaired cognition, maximal assistance with several activities of daily living, and that the resident was receiving a scheduled pain medication regimen. The H&P dated 10/26/2025 indicated the resident had the capacity to understand and make decisions. The physician orders dated 2/3/2025 included methocarbamol 750 mg by mouth three times a day for scoliosis and chronic pain, with the instruction not to give with Percocet or temazepam, and Percocet 10-325 mg by mouth every five hours as needed for moderate to severe pain. During interviews, the pharmacist, LVN, RN, and DON stated the methocarbamol and Percocet orders were vague and could be interpreted differently because the order did not specify a time frame for separation. Staff stated the orders should have been clarified to define the administration parameters. Review of the Medication Administration Audit Reports and MARs for October and November 2025 showed methocarbamol and Percocet were administered together or within an hour of each other on 15 occasions. Examples included administrations at the same time on 10/30/2025, 11/6/2025, and 11/8/2025, and close timing on multiple other dates. The DON stated the licensed nurses were responsible for clarifying vague orders, and the facility policy stated medications are to be administered as prescribed in accordance with written physician orders.
Incomplete Care Plans for Medication Use and Missing Dentures
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident 19’s use of methocarbamol. Resident 19 was admitted with diagnoses including displaced fracture of the left greater trochanter, displaced fracture of the left index finger distal phalanx, scoliosis, and chronic pain syndrome. The H&P indicated the resident had the capacity to understand and make decisions, while the MDS showed moderately impaired cognition, maximal assistance needs for several activities of daily living, and a scheduled pain medication regimen that occasionally affected sleep, therapy, and day-to-day activities. During record review, Resident 19’s orders included methocarbamol 750 mg by mouth three times a day for scoliosis and chronic pain, with instructions not to give it with Percocet or temazepam. The care plans reviewed did not include any plan addressing methocarbamol. The MDSC stated a care plan should have been developed to ensure those medications were not administered together and to include monitoring for sedation, and stated that without a care plan Resident 19 was at risk of not receiving the necessary care. The DON also stated Resident 19 would have benefited from a care plan for methocarbamol use so licensed nurses would be aware not to administer it with Percocet and temazepam. The facility also failed to develop a care plan for Resident 48’s missing dentures. Resident 48 was admitted with diagnoses including dysphagia and dementia. The H&P indicated the resident was awake, oriented to self, followed simple commands, and had limited capacity to make decisions due to cognitive impairment. The MDS showed moderately impaired cognition and assistance needs for eating, oral hygiene, dressing, hygiene, toileting, bathing, and footwear. Resident 48 stated she had lost her upper and lower dentures and had informed the SSD, who confirmed the resident reported the loss. The SSD stated no care plan was developed for the missing dentures, and the DON stated Resident 48 required a care plan with new interventions and goals for the missing dentures.
Incomplete fall assessments and care plan updates after resident falls
Penalty
Summary
The facility failed to implement fall prevention interventions for one resident after two falls. The resident was originally admitted and later re-admitted with diagnoses including reduced mobility, abnormal posture, and limited ability or inability to move one side of the body following a stroke affecting the left side. The resident's MDS dated 11/21/2025 indicated moderately impaired cognition and dependence on staff for all mobility while in and out of bed. A Change of Condition Assessment dated 11/13/2025 documented that staff found the resident on his back next to his bedside table. After the 11/13/2025 fall, the resident's Fall Risk Evaluation was incomplete, with two sections not completed, and the final evaluation indicated the resident was not at risk for further falls. The resident's care plan titled "At risk for falls," created 8/20/2025, was not revised after the falls on 11/13/2025 or 11/21/2025. The 11/21/2025 Change of Condition Assessment documented that staff found the resident with his lower back and legs on the floor and the resident stated he slid off the bed. During interview and record review, RN 1 stated a Fall Risk Evaluation had to be completed immediately after a fall, all sections had to be completed, and a short-term care plan had to be developed; RN 1 also stated no Fall Risk Evaluation was conducted after the 11/21/2025 fall and no short-term care plan was developed after the 11/13/2025 fall.
Oxygen Therapy Not Administered as Ordered
Penalty
Summary
The facility failed to ensure oxygen therapy was administered as ordered for two residents. Resident 72 was admitted with diagnoses including CHF, upper respiratory infection, and asthma, and had moderately impaired cognition. A physician order dated 11/21/2025 directed oxygen at 2 L/min with permission to increase to 3 L/min as needed, but on two observations on 12/2/2025, Resident 72 was receiving oxygen at 3.5 L/min at the bedside. During a concurrent interview and record review, RN 1 reviewed the order and stated Resident 72 should not receive oxygen above 3 L/min and that oxygen should be administered as ordered. Resident 19 was admitted with chronic respiratory failure with hypoxia, CHF, and HTN, and had moderate cognitive impairment. A physician order dated 10/19/2025 directed continuous oxygen at 3 L/min and did not indicate that the oxygen delivery was titratable. On two observations on 12/3/2025, Resident 19 was receiving oxygen at 2.5 L/min at the bedside. During interviews, LVN 2 and RN 2 both stated the resident’s orders indicated continuous oxygen at 3 L/min and that oxygen should be administered as ordered.
Inappropriate Meal Texture and Poor Palatability
Penalty
Summary
The facility failed to provide a meal that was palatable and attractively appeasing for one sampled resident. Resident 71 was newly admitted and had diagnoses including diabetes and congestive heart failure. The resident’s H&P stated she was awake, alert, and able to answer questions appropriately. Her order summary indicated a consistent carbohydrate diet with a soft and bite sized texture. During a concurrent observation and interview, Resident 71 was seen eating lunch and the meal tray contained a green-colored pureed food item. The resident stated she did not know what the green glob was, said it looked like baby food, and did not want to taste it. After tasting it, she stated it was not good and that she was not going to eat it. She also stated her food was supposed to be cut into small pieces. The DS stated a soft and bite size diet should not include pureed food and is intended for residents who can chew soft food, while the DON stated residents must receive meals according to their prescribed diet and that palatable food is important to promote food intake. The facility policy stated a soft and bite sized diet is designed for residents who experience biting limitations but can chew food items for swallowing.
Infection Control Failure With C. diff Precautions and Hand Hygiene
Penalty
Summary
The facility failed to maintain infection control measures for a resident who was placed on contact precautions for loose stools and suspected C. diff. The resident’s record showed diagnoses including type 2 diabetes mellitus, myocardial infarction, and end stage renal disease, and the resident was dependent on staff for bathing, dressing, and footwear. The resident’s SBAR on 12/1/2025 documented three loose stools and a physician order for a stool sample to rule out C. diff and to place the resident on contact isolation precautions. The infection surveillance on 12/2/2025 documented three diarrhea episodes within 24 hours, education to increase hand hygiene with soap and water, and contact and spore precautions due to loose stool. The resident’s test results on 12/3/2025 were positive for C. diff. During a concurrent observation and interview, LVN 2 was observed outside the resident’s room where the sign indicated contact precautions and to clean hands when exiting the room. LVN 2 stated the resident was on contact precaution because of loose stools and that the C. diff results were pending. In the room, LVN 2 donned a gown and gloves, checked the resident’s blood pressure, removed the gown and gloves, and then returned to the medication cart and used alcohol-based hand rub to clean her hands before preparing medications. Later, when the surveyor was observed washing hands with soap and water upon exiting the room, LVN 2 went into the restroom and washed her hands with soap and water. LVN 2 stated she should have used soap and water after removing her gown and gloves because C. diff spores are removed from hands only by soap and water and alcohol-based hand rub is not strong enough. The sign outside the room did not specify that handwashing had to be done with soap and water. LVN 2 stated the sign did not specify the handwashing method, and the Infection Preventionist stated that without proper signage staff could forget and not realize they needed to wash with soap and water. The DON stated the resident should have been placed on contact and spore precautions to specify the appropriate handwashing method, and that using the wrong hand hygiene method after attending to the resident increased the risk of spreading C. diff in the facility.
Failure to Accurately Reassess Fall Risk After Resident Fall
Penalty
Summary
The facility failed to conduct an accurate fall reassessment for one resident following a fall incident. The resident, who had diagnoses including muscle weakness, diabetes mellitus, and hemiplegia, was admitted with significant physical and cognitive impairments. The initial fall risk evaluation identified the resident as high risk, noting incontinence, balance problems, and the use of assistive devices. However, after the resident was found on the floor in their room, the subsequent fall risk evaluation did not document the recent fall, omitted the resident's incontinence and use of a wheelchair, and assigned a lower fall risk score. During interviews and record reviews, it was confirmed that the fall risk reassessment was incomplete and inaccurate. The MDS Nurse acknowledged that the evaluation did not reflect the resident's true risk factors and that the incorrect scoring could result in improper care planning. Facility policy required appropriate assessment and interventions after a fall, but these were not followed in this instance.
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop a resident-centered care plan following a fall experienced by one of the residents. The resident, who was admitted with diagnoses including muscle weakness, diabetes mellitus, and hemiplegia, was found sitting on the floor in his room. Documentation indicated that the resident required significant assistance with activities of daily living, including being dependent or requiring maximal assistance for mobility and transfers. Despite these needs and the occurrence of a fall, there was no care plan initiated to address the incident or to implement interventions for the resident's safety. Interviews and record reviews confirmed that the MDS Nurse acknowledged the absence of a care plan after the fall and recognized that the facility's policy required the development of care plan interventions to prevent further falls. The facility's policies also specified that the interdisciplinary team should create a comprehensive, person-centered care plan with measurable objectives and time frames based on the resident's assessment. However, these procedures were not followed after the resident's fall, resulting in a lack of documented interventions to address the identified risk.
Duplicate Drug Therapy Leads to Unnecessary Medication Administration
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically involving duplicate drug therapy. A resident, who had been diagnosed with asthma and COPD, was prescribed both Advair Diskus and Serevent Diskus, which both contain the active ingredient salmeterol. This resulted in the resident receiving excessive dosages of salmeterol, as both medications were administered concurrently from mid-September to mid-October. The issue was identified during a review of the resident's medication administration records, which showed that the resident was given both medications daily for 33 days. Interviews with nursing staff revealed that they administered both inhalers at the same time, under the assumption that it was acceptable due to their simultaneous scheduling. The nursing staff did not consult with a pharmacist or use a drug reference to verify the safety of administering these medications together. The Director of Nursing and the facility's pharmacists acknowledged the oversight, noting that the duplication in drug therapy was missed during the Monthly Regimen Review. The facility's policy and procedure documents emphasized the importance of consulting drug references when unfamiliar with medications, but this protocol was not followed. The manufacturer's labeling for both medications clearly warned against using them in conjunction due to the risk of overdose and serious cardiovascular side effects.
Incomplete Informed Consent for Antidepressant Medication
Penalty
Summary
The facility failed to ensure a complete informed consent form was obtained for the administration of citalopram to a resident diagnosed with major depressive disorder. The resident, who had a history of Parkinson's disease, osteoarthritis, and hypertension, was moderately cognitively impaired but had the capacity to understand and make decisions. The resident's Minimum Data Set indicated feelings of depression, and the resident was dependent on staff for daily activities. Despite this, the informed consent form for citalopram did not include the medication's dosage, frequency, or behavioral manifestations, which are necessary for informed decision-making. Interviews with the facility's RN and DON revealed that the licensed nurse was responsible for verifying that the resident and their Responsible Party were fully informed about the medication, including its dosage, frequency, and behavioral manifestations. The facility's policy required informed consent to be obtained prior to medication use, but the documentation was incomplete. This oversight meant that the resident and their Responsible Party might not have been fully informed about the treatment, potentially affecting their ability to make an informed decision regarding the resident's care.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for four residents, leading to potential negative impacts on their care plans and delivery of necessary services. For Resident 32, the MDS did not include a diagnosis of major depressive disorder, despite the resident receiving antidepressant medication and having been diagnosed by a psychiatrist. Similarly, Resident 3's MDS omitted a diagnosis of major depressive disorder, even though the resident had a long-term history of depression and was on antidepressant medication. Resident 9's MDS inaccurately reported no significant weight loss, although the resident experienced a 5% weight loss over one month. This omission could hinder the monitoring of the resident's nutritional status and the implementation of appropriate interventions to prevent further weight loss. Additionally, Resident 253's MDS failed to include a diagnosis of seizure disorder, despite the resident being readmitted to the facility with this primary diagnosis after a hospital stay. Interviews with the MDS Coordinator and the Director of Nursing highlighted the importance of accurate MDS assessments for developing patient-centered care plans. The facility's policy emphasized comprehensive and accurate assessments, yet the deficiencies in the MDS entries for these residents indicate a failure to adhere to this policy, potentially affecting the residents' care and treatment.
Failure to Develop Timely Care Plans for Residents
Penalty
Summary
The facility failed to develop timely, person-centered care plans for three residents, leading to deficiencies in their care. Resident 153, who was admitted with kidney failure and congestive heart failure, was diagnosed with cancer of the left eye and skin. Despite this diagnosis, no care plan was developed to address these new health issues. Interviews with Resident 153 and staff revealed that the resident was not informed about her dermatologist appointment, and no new treatments were provided for her skin or vision issues. The lack of a care plan meant there was no structured follow-up or interventions for her cancer diagnosis. Resident 42, who was admitted with peritonitis, intestinal obstruction, and deep vein thrombosis, was prescribed a nicotine patch for smoking cessation. However, a care plan to monitor the effectiveness and side effects of the nicotine patch was not developed until several months after the initial prescription. The delay in care planning resulted in a missed opportunity to monitor and support Resident 42's smoking cessation efforts, as evidenced by the resident being seen smoking a cigarette months after starting the nicotine patch. Resident 21, admitted with an infection of the ileostomy surgical site and acute kidney failure, also lacked a specific care plan for the care and monitoring of the ileostomy and stoma. The absence of a care plan meant there were no documented interventions for monitoring the stoma for bleeding or infection, changing the ileostomy bag, or cleaning the stoma and surrounding skin. This oversight left the nursing staff without a clear guide for providing necessary care to Resident 21, potentially compromising the resident's health and well-being.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The licensed nurses at the facility failed to review, update, and revise the care plan for Resident 21 to reflect attempts to prevent future falls. Resident 21, who has a history of falls and dementia, was admitted to the facility and had experienced multiple falls on specific dates. Despite these incidents, the care plan, which initially included interventions such as anticipating needs, placing the call light within reach, maintaining the bed in the lowest position, and encouraging appropriate footwear, was not revised after the falls on 8/9/2024 and 9/16/2024. Interviews with RN 3 and the Director of Nursing (DON) revealed that the care plan should have been revised after each fall to introduce new interventions to prevent further falls. The facility's policy and procedure on fall management emphasized the importance of updating care plans after every fall to provide appropriate assessment and interventions. However, the care plan for Resident 21 remained unchanged, resulting in a lack of interventions to prevent further falls, as evidenced by the resident's subsequent fall on 10/4/2024.
Failure to Conduct IDT Meeting After Resident Fall
Penalty
Summary
The facility failed to conduct an interdisciplinary team (IDT) meeting following a fall experienced by Resident 21 on 9/16/2024. This oversight was identified through observation, interviews, and record reviews. Resident 21, who has a history of falls and dementia, was admitted to the facility with severely impaired cognitive skills and required moderate assistance for daily activities. Despite having falls on 8/9/2024, 9/16/2024, and 10/4/2024, the IDT notes were missing for the fall on 9/16/2024, indicating that no meeting was held to address this incident. Interviews with facility staff, including a registered nurse and the Director of Nursing (DON), confirmed that an IDT meeting is required after every fall to develop a care plan and prevent future incidents. The facility's policy mandates collaboration with the attending physician and documentation of the meeting in the electronic medical record (EMR). The absence of an IDT meeting for the fall on 9/16/2024 delayed the implementation of fall prevention interventions, potentially increasing the risk of subsequent falls for Resident 21.
Failure to Prevent Accidents and Conduct IDT Review
Penalty
Summary
The facility failed to ensure that Resident 253 was free from accident hazards by not utilizing floor mats as ordered. Resident 253, who has severe cognitive impairment and is dependent on staff for daily activities, was observed without a floor mat on the left side of the bed, despite having a physician's order for floor mats on both sides as a precaution against seizures. This oversight was confirmed by both a Licensed Vocational Nurse and the Director of Nursing, who acknowledged the risk of injury if the resident were to have a seizure and fall. Additionally, the facility did not conduct an interdisciplinary team (IDT) review for Resident 21 after a fall, which is a required procedure following such incidents. Resident 21, who has a history of falls and dementia, experienced a fall on 9/16/2024, but no IDT notes were found in the electronic medical record for this incident. Interviews with a Registered Nurse and the Director of Nursing confirmed that an IDT meeting should have been held to develop a plan to prevent future falls, as falls are considered a change of condition. The facility's policies and procedures, including the Fall Management System and Significant Change of Conditions, emphasize the importance of maintaining an environment free of accident hazards and conducting IDT meetings after falls. These deficiencies highlight the facility's failure to adhere to its own policies, potentially compromising resident safety.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure safe and effective medication administration practices for four out of five sampled residents. Registered Nurse (RN 2) did not administer medication to Resident 19 in a timely manner, resulting in the resident expressing concern about not receiving her medications for blood pressure and blood sugar. Additionally, RN 2 left medications at Resident 19's bedside for self-administration, which is not an acceptable practice as it could lead to medication errors. Resident 25 experienced a delay in receiving medications due to Licensed Vocational Nurse (LVN 2) running late with the medication pass. Furthermore, RN 3 left medications at Resident 25's bedside for self-administration, despite the resident having severely impaired cognitive skills. This practice was acknowledged by RN 3 as unacceptable, as it could not be confirmed whether the resident took the medication or experienced any adverse reactions. Resident 48 also faced a delay in medication administration due to LVN 2 being sidetracked. Additionally, LVN 1 incorrectly documented administering pain medication to Resident 49, when it was actually administered by another nurse. The Director of Nursing (DON) confirmed that these practices were not acceptable, emphasizing the importance of timely medication administration to avoid negative health effects.
Failure to Identify Duplicate Drug Therapy in Resident's Medication Regimen
Penalty
Summary
The facility failed to identify a drug irregularity during the Monthly Regimen Review (MRR) for a resident receiving duplicate drug therapy. The resident was prescribed two orally inhaled medications, Serevent Diskus and Advair Diskus, both containing salmeterol, a long-acting bronchodilator. This oversight occurred between September 13, 2024, and October 15, 2024, and was not identified during the MRR, as indicated by the unmarked sections for Drug-Drug Interactions and Drug Duplications on the review form. The resident's medical history included asthma and chronic obstructive pulmonary disease (COPD), and the resident had intact cognition as per the Minimum Data Set (MDS) dated September 17, 2024. Interviews with the facility's Consultant Pharmacist and Dispensing Pharmacist revealed that neither had identified the duplicate therapy. The Consultant Pharmacist admitted to not reviewing the resident's medications and stated that he would have questioned the physician about the duplicate therapy had he noticed it. The Dispensing Pharmacist confirmed the duplicate therapy and acknowledged that it should have been flagged during the medication order review. The facility's policy on Medication Regimen Review, dated December 2023, requires the identification and documentation of drug irregularities, including duplicate drug therapy, which was not adhered to in this case.
Failure to Label Inhalers with Open Dates
Penalty
Summary
The facility failed to ensure that opened boxes of oral inhalation medications were labeled with an open date, as required by the manufacturers' guidelines. This deficiency was observed for three residents who were using inhalers for conditions such as asthma, COPD, and other respiratory issues. The medications involved included Advair Diskus, Serevent Diskus, and Arnuity Ellipta, which were found in the MedCart without the necessary open dates. During an observation, it was noted that the inhalers for three residents were opened but lacked the required open date labeling. This oversight was confirmed by an LVN, who acknowledged that the absence of an open date could lead to the use of expired medications, potentially resulting in ineffective treatment for the residents. The Director of Nursing also confirmed that the inhalers should have been labeled with an open date to ensure their effectiveness and prevent respiratory complications. The facility's policy and procedures, as well as the manufacturers' labeling instructions, clearly stated the requirement for labeling opened inhalers with an open date. The failure to adhere to these guidelines increased the risk of administering expired medications to residents, which could compromise their respiratory health. The report highlights the importance of following proper medication labeling practices to ensure the safety and well-being of residents.
Incomplete Assessment and Documentation of Itchy Area
Penalty
Summary
The facility failed to ensure that a resident's itchy area was properly assessed and documented, and that the physician's order for treatment included the specific site of administration. The resident, who had severe cognitive impairment and required assistance with activities of daily living, was prescribed Triamcinolone Acetonide Ointment 0.1% to be applied to areas of itching twice daily. However, the Medication Administration Record did not specify the location of the itching, and the progress notes lacked documentation of the site under the integumentary system assessment. Interviews with facility staff revealed a lack of clarity and communication regarding the resident's condition. A Licensed Vocational Nurse admitted that they should have assessed the resident's skin and informed the physician. A Registered Nurse was unsure of the cause of the resident's itching. The Director of Nursing acknowledged that the physician's order was incomplete, as it did not specify the site of application, which could lead to incorrect administration of the medication.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Downey
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riviera Healthcare Center | 0.8 mi | ★★★★★ | 28 | 0 |
| Colonial Gardens Nursing Home | 1.6 mi | ★★★★★ | 14 | 0 |
| Villa Del Rio Gardens | 2 mi | ★★★★★ | 0 | 0 |
| Southland | 2.1 mi | ★★★★★ | 33 | 0 |
| Downey Community Health Center | 2.2 mi | ★★★★★ | 2 | 0 |
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