Brendan House

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident representatives were contacted to provide informed consent before medication, vaccine administration, and adaptive equipment/restraints were used for 4 (#s 10, 60, 94, and 99) of 30 sampled and supplemental residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from verbal or physical abuse by staff for 1 (#43) of 30 sampled and supplemental residents. This deficient practice was corrected on 11/12/25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a severe weight loss in 1 (#5); and the facility failed to complete weekly weights for four weeks, on a new admission for 1 (#87) of 6 sampled residents for nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain evaluations and provider orders for residents to self-administer medications for 4 (#s 28, 40, 90, and 93) of 11 residents sampled for self administration capabilities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care planned assessments for seatbelt use for 1 (#1); failed to include pertinent resident care items including cardiac monitoring and CPAP settings into a comprehensive care plan for 2 (#s 12 & 19); failed to include focus, goals, or interventions on the comprehensive care plan for oxygen use and nutritional supplement use for 1 (#87); and failed to include ADL's and mobility on a comprehensive care plan for 2 (#s 30 and 87) of 43 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food at an appetizing temperature for 1 (#47) of 6 sampled residents for nutrition; and failed to ensure kitchen staff were wearing hair restraints, or wearing them properly, during food preparations. This deficient practice had the increased the risk of food borne illnesses for those who received meals in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dignity and privacy for a resident being transported to the shower room for 1 (#53); and failed to provide dignity and privacy for a resident in a dining room without bottoms on, with a catheter, and full catheter bag showing, for 1 (#2) of 3 sampled residents for dignity. This deficient practice resulted in resident #53 feeling embarrassed.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the medical provider was notified of a resident's severe weight loss, for one (#6) of 43 sampled residents. This deficient practice did not allow the physician the opportunity to plan or implement weight loss interventions.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide residents access to grievance forms and the opportunity to file grievances anonymously for 1 (#8) of 43 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep a resident free from a physical restraint for 1 (#60) of 1 sampled resident. This deficient practice caused the resident to be unable to get out of a Broda chair independently, and caused the resident to be agitated and yell to get out of the chair.

Inspectors wroteBased on interview, and record review, the facility failed to complete a baseline care plan within 48 hours of admission, to include the minimum health information necessary to properly care for 1 (#87) of 6 residents sampled for baseline care plans. This deficient practice puts the resident at risk of not receiving necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to update care plans as resident conditions and physician orders changed for 2 (#s 13 and 60) of 43 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with meals for a resident who required encouragement and one on one for eating for 1 (#60) of 5 sampled residents for nutrition. This deficient practice increased the risk for the resident not receiving necessary care and services with meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an Unstageable pressure injury received care and services to prevent worsening of a pressure injury after admission for 1 (#5) of 3 sampled residents for pressure ulcers. Resident #5 was admitted with an Unstageable pressure injury to his right heel. There was a lack of information to determine if the wound was worsening.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was provided tube feeding without complications to maintain his weight for 1 (#69) of 2 sampled residents for tube feeding.

Inspectors wroteBased on observation, interview, and record review, the facility licensed nursing staff failed to ensure a physician's order was in place for a resident's oxygen use, for 1 (#87) of 3 sampled residents for oxygen use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff adhered to standards of practice for infection control by not using proper hand hygiene and glove changes during wound care for 2 (#s 5 and 60), and failed to use proper infection control practices for 2 (#s 5 and 69) of 13 sampled residents for infection control by not adhering to practices for Enhanced Barrier Precautions by not wearing a gown during wound care, suctioning, and tube feeding. This deficient practice had increased the risk of the spread of infection for all residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received, or had the opportunity to receive, the pneumococcal vaccine series for 2 (#s 1 and 87) of 5 sampled residents for vaccinations.

Inspectors wroteBased on observations, interviews, and record review, the facility staff failed to wear hair restraints or wear them properly during food preparations to prevent hair from entering the food, which increased the risk of hair falling in the food served to the residents.

Inspectors wroteBased on interviews and record review, the facility failed to notify the physician and family of a significant weight loss for 1 (#19); and a severve weight loss for 1 (#52) of 22 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper staff hand hygiene was used during meal service in a common dining room; failed to ensure proper hand hygiene was used when delivering meal trays to resident rooms, for 6 (#s 16, 25, 46, 52, 61, and 70); and failed to ensure laboratory personnel followed infection control practices during a blood draw for 1 (#259) of 22 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure laboratory personnel in the facility provided privacy during a blood draw, for 1 (#259) of 22 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to report an alleged incident of abuse within the required 24 hour reporting period for 1 (#270) of 3 sampled residents for abuse.

Inspectors wroteBased on interviews and record review, the facility failed to protect a vulnerable resident from potential harm during an abuse investigation, for 1 (#270) of 22 sampled residents. This practice increased the risk of other vulnerable residents receiving care from the accused staff member.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide therapeutic diets to optimize the nutritional status for 2, (#s 25 and 41) of 22 sampled residents. This practice had the potential to affect any resident at risk for nutritional decline and resulted in severe weight loss for 1 (#41).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received tube feedings as ordered, for 2 (#s 36 and 77) of 22 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent and provide services necessary to promote healing on one facility acquired pressure ulcer for 1 (#62), and the wound was Unstageable, tunneling, and difficult to heal, of 23 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an adequate nutritional status for 1 (#62), resulting in a severe weight loss; and failed to provide a physician ordered therapeutic diet for 1 (#66) of 23 sampled residents. 1. During an observation on 9/12/23 at 9:22 a.m., resident #62 was in his bed in low fowler's position (head slightly elevated) and stated he was unable to reach his water on the bedside table. During an observation and interview on 9/12/23 at 2:09 p.m., staff member L was in resident #62's room assisting with a bed bath and wound dressing change. Staff member L stated resident #62, is not wanting food lately but loves the shakes, boost, I think. So, I offered him a bite of strawberries but he said no earlier. He drank the shake. He didn't eat last night either. He eats independently, but he's my buddy so I come and encourage him. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient preparation and orientation to a resident to ensure a safe discharge from the facility by discharging the resident to the front yard of a charity building, with no means of shelter, for 1 (#126) of 27 sampled residents. This deficient practice had the potential to cause the resident psychosocial harm, resulting in the resident crying and feeling distraught.

Inspectors wroteBased on observation, interview, and record review, the facility failed to care plan a resident's need for visitors to check in with the nurse's station before entering his room, related to behaviors of having inappropriate items and substances brought in, for 1 (#82) of 27 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an effective and safe discharge planning process that would effectively transition the resident to post-discharge care, and failed to involve the resident in the development of the discharge plan, for 1 (#126) of 27 sampled residents, which resulted in the resident becoming homeless, and 1 (#11) became involved as the room mate and he was upset with #126.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident had unnecessary medication removed from her orders at admission, and after not using for several weeks, for 1 (#90) of 27 sampled residents.

Inspectors wroteBased on interview and record review, the facility staff failed to properly administer a narcotic medication to 1 (#87) of 27 sampled residents, resulting in the resident receiving five times the dose ordered by the physician, a significant medication error, and creating the potential for significant harm.