Bremond Nursing and Rehabilitation Center

Inspectors wroteBased on interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 facility reviewed for infection control practices. The facility failed to ensure the previous DON's TB test was completed by 06/25/2026. This failure could place residents at risk of infection that can spark outbreaks that can spread rapidly.

Inspectors wroteBased on interviews and records review, the facility failed to ensure that medical records were accurately documented for three (3) of nine (9) residents (Resident #2, Resident #8 and Resident #9) reviewed for accurate clinical records. The facility failed to ensure Resident #2, Resident #8 and Resident #9 EMRs contained orders upon admission to the secured unit with corresponding clinical criteria to admit them to the secured unit. This failure could result in errors in care and treatment and violate resident rights.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain clinical records on each resident, in accordance with accepted professional health information management standards and practices that are complete, accurately documented, readily accessible, systematically organized and protected from unauthorized release for 3 (Resident #1, Resident #2, and Resident #3) of 4 residents reviewed for maintenance of clinical records. 1. The facility failed to ensure staff documented accurately after Resident #1 was found on the floor and sent out for evaluation on 10/12/25 and returned to the facility on [DATE].2. The facility failed to ensure staff updated the care plan for Resident #2 after she reported she had a fall on 09/15/25.3. The facility failed to ensure staff accurately documented a progress note after Resident #3 had an apparent unwitnessed fall on 10/13/25. [...]

Inspectors wroteBased on interview, observation and record review the facility failed to provide the necessary care and services for 1 of 11 (Resident #8) residents reviewed for transfer status. The facility failed to ensure that Resident #8, who was a 2 person assist in May 2025 and was changed to a mechanical transfer on 8/14/2025, did not suffer a decline in mobility. An Immediate Jeopardy (IJ) was identified on 8/15/2025. The IJ template was provided to the facility on 8/15/2025 at 4:45PM. While the IJ was removed on 8/16/2025, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure put residents at risk for decline in activities of daily living, decreased mobility, and serious harm.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure that resident environment remained as free from accident hazards as is possible, by not providing adequate supervision and assistance devices to prevent accidents for 4 of 11 residents (Resident #18, Resident #23, Resident #5, and Resident #3) reviewed for safe transfers. 1. The facility failed to ensure two staff members transferred Resident #18 via mechanical lift which resulted in Resident #18 suffering a skin tear due to being transferred by one staff member on 6/04/2025. 2. The facility failed to ensure CNA A and CNA B knew how to competently use transfer assistive device (gait belt) when performing a transfer from recliner to wheelchair for Resident #5 on 8/13/2025. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure Dietary Aide K wear a beard guard when standing over clean dishes in the dishwashing room on 08/12/2025. 2. The facility failed to ensure Dietary [NAME] M used proper hand hygiene during food preparation on 08/13/2025. These failures could place residents who ate food from the kitchen at risk for foodborne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Resident #2 and Resident #7) reviewed for ADL care. The facility failed to ensure Resident # 2 and Resident #7's nails were cleaned and did not have any rough edges on 08/12/2025. This failure could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem.

Inspectors wroteBased on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing activities program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for one of five residents ( Resident # 3) reviewed for activities. The facility failed to provide Resident #3 in room activities on the dates of 07/03/2025 thru 08/11/2025. This failure could place residents at risk for boredom, depression, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow accepted national standards for one of five residents reviewed for infection control practices. (Resident #48). The facility failed to ensure that staff wore a gown during medication administration via g-tube (a tube inserted into the stomach) on 08/13/2025 for Resident #27 when the resident was on isolation precautions ordered 08/12/2025. There was no Enhanced Barrier Precaution signage on the door nor PPE (personal protective equipment) inside or outside of Resident 27's room. This failure could place the residents, staff and visitors risk for cross contamination.

Inspectors wroteBased on interviews and record review, the facility failed to notify the resident's Ombudsman of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood for 1 of 4 residents (Resident #1) reviewed for Discharge Rights. The facility failed to notify Resident #1's Ombudsman in writing of the transfer/discharge of the resident to a behavioral hospital, the reason for the transfer/discharge, and the right to appeal. This failure could affect the residents at the facility by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and appeal processes.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food accordance with professional standards for food service of one of one kitchen reviewed for food storage, meal prep and sanitation. 1. The facility failed to seal, label and date partially frozen chicken cubes and a personal cell phone on the food prep table. 2. The facility failed to ensure dietary staff practiced proper hand hygiene and glove use. 3. The facility failed to follow recipes when preparing pureed food. 4. The facility failed to ensure regional maintenance director and a contractor wore hair nets and a beard net when entered the kitchen, the dietary staff appropriately wore a hair net, and nursing staff wore a hair net when in the kitchen. These failures could place residents at risk for health complications and foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for two of six residents (Resident # 15 and Resident #18). 1. The facility failed to ensure Resident # 15's nails were cleaned and did not have any rough edges. 2. The facility failed to ensure Resident # 18's facial hair was removed and nails were cleaned. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of five residents reviewed for accidents and hazards. (Resident #1). The facility failed to ensure CNA E followed Resident #1's care plan for the use of a mechanical lift for all transfers with two staff assist and failed to follow the manufacture instructions for use which resulted in Resident #1 receiving an improper and potentially dangers transfer. These failures placed residents at risk of injuries, hospitalization, or diminished quality of care. Finding Include: [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Resident #21) reviewed for unnecessary medications. The facility failed to ensure Resident #21 had behavior and side effect monitoring for his prescribed antidepressant medications Fluoxetine and Trazadone and his antipsychotic medication Abilify. These failures could place president at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, and decreased quality of life.

Inspectors wroteBased on interview and record reviews the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days, except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, for one of five residents reviewed for unnecessary medications. (Residents #21) The facility failed to ensure Resident #21's PRN order for Haldol dated 05/06/2024 had a stop date transcribed onto the MAR to ensure the medication did not extend beyond 14 days causing Resident #21 to receive 7 doses beyond the physician ordered stop date of 05/20/2024. This deficient practice placed residents with PRN psychotropic drugs at risk for side effects of psychotropic drugs which include nausea, drowsiness, dizziness, confusion, constipation, diarrhea, and delirium and placed residents at risk for receiving unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services for one of one kitchen staff (Dietary manager) reviewed for qualified dietary staff. The facility failed to ensure the Dietary Manger completed an approved dietary manager training course. This failure could place the residents at risk for the spread of food borne illness and residents not having their nutritional needs met.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to prepare puree food by methods that conserve nutritive value, flavor, and appearance for one of one kitchen. The facility failed to provide puree recipes for the Dietary Manager to follow when preparing puree food. This failure could affect residents on puree diet at risk of receiving inadequate diet that could affect their health.

Inspectors wroteBased on interviews and record review, the facility failed to ensure resident's medical records included documentation that indicated the resident, or their responsible party, received education of the benefits, and potential side effects, of the influenza or pneumococcal immunization, receipt of the influenza or pneumococcal immunization, or residents did not receive the influenza or pneumococcal immunization due to medical contraindication, or refusal, for 1 of 5 residents reviewed for immunizations. (Resident #8) The facility failed to document in Resident #8's medical records for having had received education, whether by self or with responsible party, of the benefits, and potential side effects, of the influenza immunization and receipt of the of the pneumococcal immunization or having had not received the pneumococcal immunization due to medical contraindication or refusal. [...]

Inspectors wroteBased on interview and record reviews, the facility failed to implement their policy to ensure the residents, or their responsible party, received education of the benefits and risks, or potential side effects of Covid-19 immunizations, receipt of Covid-19 immunizations, or the residents did not receive the Covid-19 immunizations, due to medical contraindication, or refusal, for 1 of 5 residents who were reviewed for immunizations. (Resident #7) The facility failed to document in Resident #7's medical records for having had received education, whether by self or with their responsible party, of the benefits and risk, and potential side effects, of the Covid-19 immunization, receipt of the of the Covid-19 immunization, or having had not received the Covid-19 immunization due to medical contraindication or refusal. [...]

Inspectors wroteBased on interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet a resident's medical and nursing needs for one (Resident #1) of four residents reviewed for care plans, in that: The facility failed to develop a care plan for Resident #1's sacrum (a shield shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis) stage four pressure ulcer and the care plan did not address his non-compliance with treatment. This failure could place residents at risk for not having their individual care needs met, errors in providing care, poor wound healing/worsening wound condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for one of two kitchen staff (CK/DM) reviewed for sufficient staff. The dietary manager (CK/DM) at the facility did not have a dietary manager certificate. This failure placed residents at risk of unsatisfying food and food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with dignity and respect and care for residents in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for three of four residents (Resident #16, Resident #5, and Resident #10) reviewed for dignity. 1. Resident #16's door and curtain were left open while he received wound care to his ankle. 2. Resident #5's wound care was performed with the door to the hallway open and the privacy curtain was not pulled. 3. Resident #10's wound care was performed with the privacy curtain partially closed, exposing his buttock and leg to anyone passing by in the hallway. These failures placed residents at risk for an undignified existence due to exposure of body parts during medical treatments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for food storage, preparation, and service. 1. The facility dishwasher was out of sanitizer and still being used to wash dishes. 2. The CK/DM failed to sanitize the puree bowl between puree dishes and used unsanitized tongs to handle sausage during the puree process. 3. There was no system in place to accurately monitor holding temperatures for the pureed foods. These failures placed residents at risk of food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one of two smoking areas (Smoking Area 1)observed for hazards The facility Smoking Area 1 had a plastic trash can in use and no useable metal trash cans, and there was a splintered board on the seat of one of the porch swings in the area. These failures placed residents at risk of burns and lacerations to the skin.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for one of one residents (Resident #2) reviewed for respiratory care. The facility failed to ensure Resident #2's oxygen tubing was dated with the date it was changed. This failure could place all residents who use respiratory equipment at risk for respiratory infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for one of one medication carts and one of one loose pill reviewed for medication storage. 1. The facility failed to ensure the medications for Resident #2 were placed inside of the medication cart when the nurse left the cart for 12 minutes. 2. The facility failed to secure Resident #16's Oxcarbazepine after it fell on the floor. This failure could place residents at risk of ingesting unprescribed medications resulting in adverse health consequences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for one of one staff (LVN A) observed for infection control practices. 1. LVN A used a contaminated glove to touch and administer Resident #10's medications. 2. LVN A failed to sanitize her hands and replace her gloves prior to performing wound care for Resident #5. These failures could place residents who require assistance with medication administration and wound care at risk for healthcare associated cross-contamination and infections.