Inspection Reports for Brookstone Retirement Center

The facility failed to maintain hot water temperatures at resident-used bathroom sinks within the required range of 100 to 116 degrees Fahrenheit, with readings exceeding 120 degrees F in multiple rooms despite thermostat adjustments and ongoing efforts to correct the issue.

The facility failed to ensure that 8 ounces of milk or equivalent dairy products were served three times daily to 6 of 28 residents in the Special Care Unit (SCU). Observations and interviews confirmed milk was not served to these residents during lunch on 07/10/24 and breakfast on 07/11/24 despite milk being available and listed on the menu.

The facility failed to ensure follow-up for a resident's portable oxygen needs, resulting in lack of portable oxygen availability. Additionally, residents requiring feeding assistance were not consistently assisted in an unhurried manner, with staff often standing rather than sitting while feeding. The facility also failed to administer medications as ordered, with one resident receiving duplicate diabetic medications due to pharmacy and facility communication errors.

The facility was found deficient in multiple areas including failure to assure tuberculosis testing for staff upon hire, failure to provide adequate supervision for a resident with repeated falls resulting in serious injury, failure to assure physician notification for missed medications on dialysis days, failure to complete required licensed health professional support evaluations for a resident with restraints, failure to maintain clean kitchen air vents and proper food safety, failure to administer medications as ordered including errors in inhaler and insulin administration, and failure to provide required special care unit staff training.

The facility failed to meet several physical plant and safety requirements including lack of sprinkler heads and fire detection devices in closets, missing or outdated fire safety inspection reports, improperly directed exit signs, unsafe storage of portable oxygen cylinders, use of extension cords in place of permanent wiring, trip hazards, inadequate fire drill rehearsals, malfunctioning emergency lights and exit signs, corridor doors not closing or latching properly, compromised fire rated walls and ceilings, improper storage near sprinkler heads, presence of prohibited portable electric heaters, and non-functioning exhaust ventilation in certain areas.

Multiple deficiencies were cited related to physical plant maintenance including unserviced HVAC grilles, unsecured plumbing fixtures, malfunctioning doors and light fixtures, breaches in fire-resistant ceiling construction, non-operational emergency lighting, dropped sprinkler head escutcheons, use of prohibited portable electric heaters, and inadequate exhaust ventilation in certain rooms.

The facility failed to send a resident (Resident #6) to the hospital in a timely manner for medical treatment despite multiple requests from the resident's Power of Attorney and family members. The Medication Aide did not recognize the need for hospital evaluation and delayed sending the resident out until the evening shift. The resident was diagnosed with COPD with acute exacerbation at the hospital.

The facility was found deficient in multiple life safety and physical plant areas including outdated fire alarm inspection, obstructed exit paths, missing guardrails, trip and fall hazards, unmaintained sprinkler heads, improperly secured exit gates, non-functioning exit signs, fire doors not latching, emergency lights not working, compromised fire rated walls, improper storage of medical oxygen cylinders, lack of monthly inspections for kitchen suppression system, faulty GFCI receptacles, and loosely mounted toilets.