Brookdale Skyline-alr

“Based on observation, interview and record review, the residence failed to store potentially hazardous foods at or above 135 degrees Fahrenheit (F), affecting the 43 current residents.Findings include:ObservationsObservations were conducted during lunch meal service in the dining room on 3/24/26 at 11:10 a.m. Internal food temperatures were taken from food that was on the steam table. The meatloaf measured at 117.9°F and the potatoes measured at 134.1°F. During the observation, kitchen staff identified that one of the steam tables was not working and a work order was submitted. Additional observation later that day at approximately 5:15 p.m. revealed the steam table was still not working. The assisted living resident (ALR) council notes dated 12/2/25 read in part, "Food is good, food is cold and not always well done." Family council meeting minutes dated 3/3/26 read in part, the food served to residents was not consistently provided at the required temperature.On 3/24/26 at 4:00 p.m. the executive chef (EC) stated cooked meals were transported from the main kitchen to the kitchen in an electronic hot box used to keep food warm during transport. He continued, once the food arrived in the kitchen, kitchen staff transferred it to a steam table for service. The EC further mentioned that hot foods were expected to be temperature-checked throughout transport and service and maintained above 135°F. The EC confirmed that the food temperature at lunch serving time was lower than standard.”

“Based on record review and interview the residence failed to prevent staff from administering another residents medication to another resident affecting two of five sample residents (#1 and #5). (Cross-reference T0430)Findings Include:1. Record ReviewResident #1 was admitted to the residence 5/7/25 with a diagnosis of hypothyroidism, chronic kidney disease, hypertension and cognition impairment.A care plan dated 5/7/25 read that Resident #1 would receive assistance with all of their medications.An incident investigation dated 5/18/25 read that Staff #4 informed the LPN that she gave Resident #1 a different resident's medications.A progress note dated 5/18/25, read that Resident #1 was given the wrong medications by the day shift QMAP and that Resident #1 was monitored for any adverse reactions. 2. InterviewOn 6/16/25 at approximately 9:00 a.m., Resident #1 stated that she recalled the incident on 5/18/25 when she was given the medication that was prepared for Resident #5. She stated that she did not recall the administrator or the LPN approaching her about the incident. On 6/16/25 at approximately 3:30 p.m., the LPN stated that Staff #4 reported that she gave Resident #1 the medications that she prepared for Resident #5 on 5/18/25. She stated that Resident #1 reported not sleeping well and feeling anxious because of the incident with her medications. On 6/16/25 at approximately 5:00 p.m., the administrator stated that she was aware of the incident that occurred on 5/18/25. She stated that she expected qualified medication administration personnel (QMAP) to check the medication name, check the medication administration record and ask the resident their name before medication was administered. Similar deficient practice was found for Resident #5.”

“Based on record review and interview the residence failed to prevent staff from administering another residents medication to another resident affecting two of five sample residents (#1 and #5). (Cross-reference T0430)Findings Include:1. Record ReviewResident #1 was admitted to the residence 5/7/25 with a diagnosis of hypothyroidism, chronic kidney disease, hypertension and cognition impairment.A care plan dated 5/7/25 read that Resident #1 would receive assistance with all of their medications.An incident investigation dated 5/18/25 read that Staff #4 informed the LPN that she gave Resident #1 a different resident's medications.A progress note dated 5/18/25, read that Resident #1 was given the wrong medications by the day shift QMAP and that Resident #1 was monitored for any adverse reactions. 2. InterviewOn 6/16/25 at approximately 9:00 a.m., Resident #1 stated that she recalled the incident on 5/18/25 when she was given the medication that was prepared for Resident #5. She stated that she did not recall the administrator or the LPN approaching her about the incident. On 6/16/25 at approximately 3:30 p.m., the LPN stated that Staff #4 reported that she gave Resident #1 the medications that she prepared for Resident #5 on 5/18/25. She stated that Resident #1 reported not sleeping well and feeling anxious because of the incident with her medications. On 6/16/25 at approximately 5:00 p.m., the administrator stated that she was aware of the incident that occurred on 5/18/25. She stated that she expected qualified medication administration personnel (QMAP) to check the medication name, check the medication administration record and ask the resident their name before medication was administered. Similar deficient practice was found for Resident #5.”

“Based on record review and interview the residence failed to comply with all occurrence reporting requirements by state law affecting two of five sample residents (#1 and #5). (Cross-reference B0714)Findings Include:1. Record ReviewResident #1 was admitted to the residence 5/7/25 with a diagnosis of hypothyroidism, chronic kidney disease, hypertension and cognition impairment.A care plan dated 5/7/25 read that Resident #1 would receive assistance with all of their medications.An incident investigation dated 5/18/25 read that Staff #4 informed the Licensed Practical Nurse (LPN) that she gave Resident #1 a different resident's medications. On 6/16/25 the department quality assurance team confirmed that the incident reported on 5/18/25 of Resident #1 given another resident's medications was a reportable incident. 2. InterviewOn 6/16/25 at approximately 9:00 a.m., Resident #1 stated that she recalled the incident on 5/18/25 when she was given the medication that was prepared for Resident #5. She stated that she did not recall the administrator or the LPN approaching her about the incident. On 6/16/25 at approximately 3:30 p.m., the LPN stated that Staff #4 reported that she gave Resident #1 the medications that she prepared for Resident #5 on 5/18/25.On 6/16/25 at approximately 5:00 p.m., the administrator stated that she was not aware that the incident on 5/18/25 was a reportable incident. Similar deficient practice was found for resident #5.”

“Based on observations and interviews, the residence failed to provide a variety of foods in sufficient amounts to satisfy resident appetites and failed to make available appealing substitutes of similar nutritional value, affecting 95 current residents. (Cross-reference T2140)Findings include:On 6/16/25 at 12:00 p.m., observation of the lunch service revealed that the residence did not have an alternative option listed on the "Always Available" alternative options menu.Resident council meeting minutes dated 5/13/25 at 10:40 a.m. read in part: "Recurring feedback about the oranges served lately. They are hard to peel and don ' t taste good," and "Still issues with consistency regarding portion size."On 6/16/25 at 8:30 a.m., Resident #1 stated that the residence often ran out of food options listed on the menus. She stated the food was sometimes cold and served late.On 6/16/25 at 10:30 a.m., Resident #4 described the food services as poor. He explained that portion sizes were inconsistent and the food did not always match the menu. He also stated that wait times had exceeded an hour.On 6/16/25 at 11:00 a.m., Resident #7 stated that the food was not good and often not cooked correctly. She explained it appeared the residence used the cheapest options available.On 6/16/25 at 11:15 a.m., Resident #6 stated that the food was bland, poorly prepared, and not as advertised. She reported receiving cut-up chicken instead of the fried chicken listed on the menu, while others at her table received whole pieces.On 6/16/25 at 12:00 p.m., Resident #1 stated she requested a cheeseburger instead of the main entrée, but was told by staff that supplies were unavailable.On 6/16/25 at 12:05 p.m., Staff #6 confirmed the kitchen did not have hamburger buns and that Resident #1 did not want a hamburger on sliced bread. Staff #6 added that the kitchen sometimes ran out of listed options and relied on deliveries from the "main office." She said staff were not always available to retrieve needed items.On 6/16/25 at 5:00 p.m., the administrator stated she was aware of complaints regarding unavailable menu items. She noted the issue had been discussed at resident council and food committee meetings. She confirmed reports that the food was not palatable and acknowledged that wait times of 45 minutes to an hour were unacceptable. She stated that the kitchen posted a notice outside the dining room if substitutions are necessary and confirmed that she expected all "Always Available" alternatives to be available.On 6/16/25 at 5:00 p.m., the executive director stated that residents had complained about the food ' s quality, timeliness, and unclear labeling. He emphasized that meals should be accurately named, supplies should be on hand, and staff should obtain needed items from the store when necessary. He stated that ensuring good meals was very important, especially in this setting.”

“Based on record review and interviews, the residence failed to provide a therapeutic diet for one of the eleven sample residents (#3). (Cross-reference T2112)Findings include:The residence ' s approved diet policy, dated 5/2025, read in part: "Diets other than those listed on the approved diets policy may be offered under the direction and supervision of a local registered/licensed dietitian and in compliance with state regulations."Resident #3 was admitted on 3/4/25 with a diagnosis of celiac disease.A practitioner ' s order, dated 4/5/23, read in part: "gluten-free diet."A care plan, dated 10/11/24, read in part: "resident receives the following diet: gluten-free diet."An aftercare summary from an annual wellness check dated 5/9/25 read in part: "Celiac disease, stable - this could be contributing to decreased absorption of calcium and [vitamin] D - she tries to watch her diet but loves to eat the sweets served at her facility."On 6/16/25 at 3:45 p.m., Staff #5 stated she was unaware that Resident #3 had a practitioner-ordered gluten-free diet.On 6/16/25 at 3:50 p.m., Staff #6 stated she was unaware that Resident #3 had celiac disease or a gluten-free diet order.On 6/16/25 at 4:20 p.m., the Licensed Practical Nurse (LPN) stated that Resident #3 received a regular diet. She explained she was unaware that Resident #3 had celiac disease or a practitioner-ordered gluten-free diet.On 6/16/25 at 5:00 p.m., the administrator stated she was aware Resident #3 had celiac disease and a gluten-free diet order. She explained that "gluten-free is not one of the approved diets" and that if it were, the dietitian would provide special menus. She added that gluten-free options were available to all residents at each meal.”

“Based on observation, record review, and interview, the residence failed to notify the department of a change in the administrator, affecting 36 current residents.Findings include:On 10/15/24 the administrator of record was not the acting administrator at the residence.On 10/16/24 at approximately 11:00 a.m., the acting administrator said she had been in the administrator position for approximately six months. She said she was unsure who was responsible for updating the administrator on record.”

“Based on record review and interview the residence failed to detail in each resident's care plan the individualized approaches necessary to address fall risk, affecting three of six sample residents (#1, #5, #6).Findings include:1. Resident #6 was admitted to the residence on 7/1/22 with diagnoses of Alzheimer's disease and type two diabetes. Record review revealed the resident fell three times from 9/6/24 to 10/11/24.Specifically, fall reports read that Resident #6 had a fall after losing his balance on 9/6/24 in his living room and was experiencing neck pain following the fall. Resident #6 had another fall after losing his balance on 9/12/24, which resulted in a skin tear to his left palm. A care plan, dated 4/10/24, read in part that the resident required universal fall precautions. However, the care plan did not include individualized approaches necessary to address fall risk as required.On 10/15/24 at approximately 11:30 a.m., Staff #3 stated Resident #6 had a recent increase in falls with minor injuries.On 10/16/24 at approximately 10:30 a.m., the administrator stated they were not aware the residence had not updated care plans with any interventions to help mitigate falls after the residents fell. 2. Similar deficient practice was found for Residents #1 and #5.”

“Based on record review and interview, the residence failed to re-assess residents every six months for the need of a secure environment, affecting three of six sample residents in the secure environment (#1, #5, #6). Findings include:1. Resident #6 was admitted to the residence on 7/1/22 with a diagnosis of Alzheimer's disease. The record for Resident #6 contained an evaluation for the secure environment, dated 6/28/22. However, the record contained no further evidence that the residence re-assessed the resident every six months for the need of a secure environment. On 10/15/24 at approximately 10:30 a.m., the administrator said he did not know the residence was required to assess residents in the secure environment every six months to determine their continued need for a secure environment.2. Similar deficient practice was found for Residents #1 and #5.”