Brentwood Health Care Center

Inspectors wroteBased on observation, interview and record review the facility failed to test a tab alarm (a tab placed on wheelchair with sensors connected to the resident that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) for one of three sampled residents (Resident 2). This deficient practice placed Resident 2 at risk of getting up undetected and having a fall. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the deterioration of pressure injuries (localized damage to skin and underlying soft tissue, usually over bony prominences [heels, hips, tailbone], caused by prolonged pressure, friction, or [NAME]) and provided care and services consistent with professional standards of practice for one out of three sampled residents (Resident 1) who had multiple pressure ulcers/injuries by failing to:1. Set the low air loss (LAL - a medical bed system with air-filled cells that let out tiny amounts of air through microscopic holes to keep the user's skin cool, dry, and moisture-free. It acts like a floating surface that reduces pressure on the body, actively prevents bedsores, and helps heal existing skin ulcers. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed nurses had specific competencies and skill sets necessary to adequately, assess, describe, and report the development of a new Pressure Ulcer (PUs- localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), for one of the three sampled residents (Resident 1) who had a new PU to the left shin to the physician. This failure resulted in Resident 1's delay in getting treatment for the left shin unstageable (deep wound where the true depth and severity cannot be seen because it is covered by dead tissue (slough) or thick, hardened, black/brown scabs known as eschar) pressure injury which could have resulted in further deterioration of the PU, infection, sepsis, organ failure, and or death. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary staff did not store foods in the kitchen beyond their expiration date and meat was not sitting in a dark reddish liquid. This deficient practice of storing food in the kitchen beyond their expiration date and meat sitting in a dark reddish liquid may cause all residents possible serious complications from foodborne illnesses (refer to illnesses such as nausea, vomiting, and diarrhea, caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on observation, interview and record review the failed to ensure that one of two sampled resident (Resident 34) was provided with alternative meal/s that was appealing, nutritional, and appetizing. This deficient practice had the potential to result in the resident missing a meal, that could lead to weight loss. A review of Resident 34's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included Malignant Neoplasm of Colon (Abnormal Cell growth in the colon (the final part of the digestive system that absorbs water, from digested food), which may lead to tumors (a lump or mass of extra cells that grow abnormally in the body) in the colon, anemia (blood disorder in which the blood has a reduced ability to carry oxygen to the rest of the body), and muscle weakness (a reduced ability to accomplish everyday tasks). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of the two sampled residents (Resident 9) Preadmission Screening and Resident Review (PASRR - a screening evaluation used to determine whether placement in a long term care facility is appropriate for the resident) Level I (a tool that helps identify possible serious mental illness and/or intellectual/development disability) assessment was accurately completed. This deficient practice of failing to accurately complete PASRR Level I assessment for Resident 9, placed Resident 9 at increased risk to not receive the necessary/appropriate care and services.

Inspectors wroteBased on observation and interview, the facility failed to provide reasonable accommodation resident preferences and choices for one out of 18 sampled residents (Resident 21). This deficient practice resulted in Resident 21 receiving bed baths instead of showers and had the potential to result in the Resident 21 inability to attain and maintain his/her highest practicable well-being with activities of daily living (ADLs). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently honor food preferences that had been requested for one (1) out of 18 sampled Resident (Resident 51)These deficient practices had the potential to result in weight loss due to inadequate calories in residents who did not receive the correct amount or food items of their choices of their preference. [...]

Inspectors wroteBased on interview and record review the facility failed to arrange and confirm transportation to a doctor's appointment for one of three sample residents, (Resident 1). This deficient practice caused Resident 1's appointment to be changed unnecessarily.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food storage practices in the kitchen for by failing to ensure expired canned food, corned beef hash 6-pound (lbs., unit of measurement) 12 ounce (oz, is a unit of measurement) was not stored in the same location as non-expired food to be served to residents in the food storage area along with all other canned foods not expired. The corned beef hash was expired on 10/2022. This deficient practice had the potential to result in harmful bacteria growth and the consumption of spoiled food that could lead to foodborne illness (caused by contamination of food and occur at any stage of the food production, delivery, and consumption chain) in 57 of 57 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided dignified dining experience while assisting two of 15 sampled residents (Residents 4 and 58) during meals; by ensuring Residents 4 and 58 were fed at eye level to maintain face-to-face contact with the residents. This deficient practice had the potential to result in feelings of decreased self-esteem and self-worth for Resident 4 and Resident 58). b. During a review of Resident 58's admission record indicated the facility admitted the resident on 9/26/2024 with diagnoses that included dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing) and muscle weakness (a lack of strength in the muscles). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide on-going activities, based on comprehensive assessment and resident's preferences, that meets the interests and to support the physical, mental, and psychosocial well-being of 57 of 57 facility Residents. This deficient practice had the potential to result in lack of feelings of well-being and meaningfulness for the resident.

Inspectors wroteBased on interview, and record review, the facility failed to create a comprehensive care plan (a resident-specific plan with defined clinical goals and interventions used to manage identified medical issues or other areas of concern) to meet the needs of two of five sampled residents (Residents 58 and 164) by failing to: -Develop a care plan for Resident 58's psychotropic (a medication that affects behavior, mood, thoughts, or perception) medications and their targeted behavior of visual hallucinations for Resident 58. - Develop a care plan for Resident 164's activities and anticoagulant (medication used to prevent blood clots) medication. These deficient practices placed Residents 58 and 164 at increased risk for suboptimal care from facility staff in these care areas leading to diminished physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate monitoring of anticoagulants (blood thinner; a substance that hinders the clotting of blood) and antidepressants (medication used to treat depression [mental health that involves persistent feeling of sadness, loss of interest and low mood that lasts for a long time] for two of ten sampled residents (Resident 6 and Resident 164). These deficient practices had the potential to result in complications from the use of antidepressants and anticoagulants such as bruising, bleeding to Resident 6 and Resident 164.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility document titled, Facility Verification of Informed Consent, (a principle in medical ethics, medical law, and media studies, that a patient must have sufficient information and understanding before making decisions about their medical care) form was fully completed and properly executed for psychotropic (medications that affect the mind, emotions, and behavior) medication for two of five sampled residents (Residents 58 and 164). This deficient practice had the potential for Residents 58 and 164 not to be fully informed of the risk and benefits of the psychotropic medication they were receiving.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment by failing to ensure a pest free environment for one of six sampled residents (Resident 214). This deficient practice resulted in Resident 214 being bitten by ants and a potential of a facility wide infestation of ants and other residents being affected by a wider infestation.

Inspectors wroteBased on observation, interview and record review, the facility's interdisciplinary team (IDT-- a group of health care professionals with various areas of expertise who work together toward the goals of their clients) failed to ensure that one of 13 sample residents (Resident 53) did not keep medications at the bedside without a physician's order and/or without being assessed to determine if the resident is capable to self-administer medications. This deficient practice resulted in Resident 53 keeping a white powder like substance inside the medication dispensing cup and self-applying the white powder under the breasts. This deficient also, had the potential for the white powder to be accessed and used by unintended person.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the residents right to formulate an advanced directive (a legal document indicating resident preference on end-of-life treatment decisions) was recorded for two of 14 sampled residents (Residents 23 and 26). This deficient practice violated Residents 23 and 26 right to be fully informed of the option to formulate advance directives and had the potential to cause conflict with health care wishes for residents 23 and 26.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 164's) medical records had accurately documented assessment reflective of the resident's use of an anticoagulant (a substance that prevents or treats blood clots in the heart and blood vessels [tubes that carry blood throughout the body]). This deficient practice resulted in Resident 164's medical records being inaccurate and missing vital information of services being rendered to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 6 (CNA 6) was trained and had the appropriate qualifications to serve as a qualified therapeutic recreation specialist or an activities professional to support the physical, mental, and psychosocial well-being of 57 of 57 residents in the facility. This deficient practice had the potential to result in a decline in the physical, mental, and psychosocial well-being the 57 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan (a document outlining a detailed approach to care customized to an individual resident's need) with measurable goals and interventions to address care and treatment of a resident with dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning) for one of one sampled resident (Resident 58). This deficient practice had the potential to negatively affect the delivery of services to Resident 58.

Inspectors wroteBased on observation, interview, and record review, the failed to obtain a physician's order and clinical indication to apply medication for one of 13 sample residents (Resident 53). This deficient practice resulted in Resident 53 applying the antifungal powder under the breasts without a physician's order and clinical indication for the antifungal powder.

Inspectors wroteBased on interview and record review the facility failed to document an accurate fall risk assessment (an evaluation to determine a resident's risk for fall based on different variables) for one of three sampled residents, (Resident 1). This deficient practice had the potential to place Resident 1 at risk for fall(s) causing injuries or even death.

Inspectors wroteBased on observation and interview, facility failed to ensure removal and discarding of discontinued medications for four of four sampled discharged residents (Resident 8, 9, 10 and 14) from the medication storage room per facility's policy. This deficient practice resulted in unsafe storage of the medication, and possibly Residents 8, 9, 10 and 14 inabilities to get the prescribed medications paid by residents ' insurance.

Inspectors wroteBased on interview and record review, the facility failed to, for eight of 22 sampled residents (Resident 11, 21, 28, 29, 36, 126, 127 and 227),: 1. Inform or offer advanced directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) information, 2. Maintain a current copy of resident's advance directive in resident's clinical record 3. Followed up and provided additional information on advanced directive upon request. These deficient practices violated the residents' and/or the representatives' right to be fully informed of the option to formulate advanced directives and had the potential to cause conflict with health care wishes for Residents 11, 21, 28, 29, 36, 126, 127 and 227.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 10 of 10 sampled residents (Residents 6, 28, 38, 229, 7, 16, 27, 52, 57, and 127) were free from physical restraint by a. failing to ensure the use of side rails (SR) are properly assessed in the Minimum Data Set (MDS - a standardized assessment and care-screening tool). b. failing to ensure the physician's order for one fourth (1/4) side rails (SR) up as enablers for mobility were applied. These deficient practices had the potential to result in entrapment and injury and residents not being treated with respect and dignity with the use of restraints.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a preadmission screening assessment was done for a resident who was diagnosed with a mental illness prior to admission in the facility for one of one sampled resident (Resident 21). This deficient practice had the potential for not receiving the necessary and appropriate psychiatric (relating to mental illness or its treatment) level of treatment and evaluation in the facility. Cross Reference: F645.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe provision of pharmaceutical services by failing to: 1. Ensure Resident 6's self-administered medication was properly stored. 2. Ensure one of two medication storage refrigerator (refrigerator 1's) temperatures were within the acceptable range. 3. Ensure proper labeling of an opened foil pack of DuoNeb (medication to treat symptoms associated with lung disease) for Resident 6. 4. Ensure ophthalmic (eye) medications were refrigerated per pharmacy for Resident 175 and 232. These deficient practices had the potential to compromise the safety and effectiveness of medications, resulting in possible medication errors.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident's right to be treated and dignity and to self-determination for two of the 15 sampled residents when: 1. Licensed Vocational Nurse 3 (LVN 3) asked Resident 64 what was Oxycodone (controlled strong pain medication) the maximum dose per day. 2. Resident 4 (female) shared a bathroom with male residents. As a result, Resident 67 felt uncomfortable and Resident 4 felt bad and disgusted every time she had to use the bathroom.

Inspectors wroteBased on observation, interview, and record review, the licensed nursing staff failed to ensure that the residents and/or responsible party (RP) were informed in advance, of the risks and benefits of psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior) for one of 15 sampled residents (Resident 38). This deficient practice violated the residents' right to make an informed decision regarding the use of psychoactive medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a preadmission screening assessment was completed for one of threee sampled residents (Resident 21), who was diagnosed with a mental illness prior to admission in the facility. This deficient practice had the potential for Resident 21 not receiving the necessary and appropriate psychiatric (relating to mental illness or its treatment) level of treatment and evaluation in the facility. Cross Reference: F641.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for four of 35 sampled residents (Residents 6, 16, 28 and 38) by failing to ensure: 1. Comprehensive care plan was developed and implemented for Resident 16's levetiracetam (medication to treat seizure [a sudden, uncontrolled electrical disturbance in the brain]) use. 2. Residents 6, 28 and 38 had the proper care plan for bed side rails per physician order. These deficient practices had the potential to result negative impact on Residents 6, 16, 28 and 38's health and safety, as well as the quality of care and services received.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 22 sampled residents (Resident 9) psychoactive medication clonazepam (klonopin- a long-acting benzodiazepine with intermediate onset commonly used to treat panic disorders, severe anxiety, and seizures) 1. Was necessary to treat a specific diagnosis and documented condition. 2. Pharmacist recommendations were followed. This deficient practice had the potential to place Resident 9 at risk of receiving unnecessary medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the appropriate setting of the low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds) was properly set up for two of two sampled residents, (Residents 38 and 57) according to the residents' needs and professional standard of care. This deficient practice placed Residents 38 and 57 at risk of poor wound healing of the current pressure ulcer (skin and soft tissue injuries that form as a result of constant or prolonged pressure exerted on the skin) and had a potential to develop new pressure sores/wounds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy and procedure (P&P) titled, Personal Alarms, for one of 22 sampled residents, (Resident 28) who are at risk for falls. This deficient practice placed Resident 28 at risk for fall and sustain an accidental injury.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure resident received appropriate treatment and services to prevent urinary tract infections (UTI-an infection in any part of your urinary system your kidneys, ureters, bladder and urethra) for one of three sampled residents (Resident 177) by failing to ensure Resident 177's indwelling urinary (foley) catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) was placed below the level of the bladder at all times. This deficient practice had the potential to result in urinary tract infections for Resident 177. This deficient practice had the potential for Resident 177 to be at risk for complications related to indwelling catheters such as UTI.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two of 15 sampled residents (Residents 11 and 36) were accurately assessed and monitored by failing to: 1. Identify and assess prevent unplanned significant weight loss of 11.4 pounds (lbs) (6.8 percent) in 9 days for Resident 11. 2. Ensure Resident 36 who was on a fluid restriction, received the daily fluids per physician's order and resident's care plan. These deficient practices resulted in Resident 11 having unplanned significant weight loss of 11.4 pounds in 10 days and placed her at a risk for malnutrition; it also had the potential to cause either fluid overload or dehydration for Resident 36.

Inspectors wroteBased on observation, interview and record review, the facility failed to effectively manage pain for one of 15 sampled residents (Resident 64) by not following physician's medication order. This deficient practice resulted in Resident 64 experienced unnecessary pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of the 22 sampled residents (Resident 9) psychoactive medication clonazepam (klonopin- a long-acting benzodiazepine with intermediate onset commonly used to treat panic disorders, severe anxiety, and seizures [is a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations or states of awareness]), by failing to ensure: 1. Klonopin was necessary to treat a specific diagnosis and the condition documented. 2. The Pharmacist's recommendations were followed. These deficient practice had the potential to place Resident 9 at risk of receiving unnecessary medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of five sampled residents (Resident 7's) psychotropic (relating to or denoting drugs that affect a person's mental state) medication regimen was managed and monitored to promote or maintain the highest practicable mental, physical, and psychosocial well-being by failing to ensure: 1. The implementation of monitoring episodes of anxiety for Resident 7's alprazolam (anti-anxiety medication) use. 2. The implementation of monitoring for any potential side effect and/or adverse reaction for Resident 7's alprazolam use. 3. The implementation of monitoring episodes of depression for Resident 7's citalopram hydrobromide (anti-depressant medication) use. 4. The implementation of monitoring for any potential side effect and/or adverse reaction for Resident 7's citalopram hydrobromide use. 5. [...]

Inspectors wroteBased on interview, and record review, the facility failed to maintain accurate medical record in accordance with accepted professional standards and practices for one of 22 sampled residents (Resident 33) by failing to ensure Resident 33's change of condition documentation on 10/25/2023 was documented via late entry. Resident 33 was transferred to an acute care hospital (GACH) on 10/24/2023. This deficient practice had the potential to negatively impact the delivery of service given to Resident 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of one sampled emergency crash cart (set of trays, drawers or shelves on wheels used in a medical facility for transporting and dispensing emergency equipment at site for life support protocols): 1. Ensure crash cart was readily available; Registered Nurse 1 (RN 1) did not know the code and/or which key to use when opening the emergency crash cart. 2. Ensure crash cart log was checked and updated on a daily basis and as needed. These deficient practices had the potential of delayed provisions of emergency care for all the current residents who wishes to have full treatment in a life-threatening situation.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for three of three sampled residents (Residents 1, 2 and 5) by failing to: 1. Implement a comprehensive and resident-centered care plan regarding Resident 1 and 2's peripherally inserted central catheter (PICC line-type of catheter that is placed in a large vein that allows to give medications intravenously [IV-given via vein]). 2. Develop and implement a resident-centered care plan when Resident 5 refused COVID-19 (a viral infection, highly contagious, that easily transmits from person to person, causing respiratory problems and may cause death) vaccination. These deficient practices had the potential to fail during the delivery of necessary care and services to Residents 1, 2 and 5.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two of four sampled residents (Residents 1 and 2) with Intravenous (IV-given via vein) catheter was provided safe care to prevent complications. Residents 1 and 2 had a Peripherally inserted central catheter (PICC line-type of catheter that is placed in a large vein that allows to give medications intravenously) line and the dressing was not changed per facility's policy. This deficient practice had the potential to place Residents 1 and 2 at risk for developing complications such as inflammation of the vein and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure that COVID-19 (a viral infection, highly contagious, that easily transmits from person to person, causing respiratory problems and may cause death) booster vaccination was consented properly and complete, educated upon refusals with documentation when offered to one of eight sampled residents (Resident 5). This failure had the potential to result in Resident 5's COVID-19 infection.