Brentwood Rehabilitation and Healthcare Ctr (the)

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when three out of four nurses observed made four errors out of 26 opportunities, resulting in a medication error rate of 15.38%. Those errors impacted three Residents (#66, #106, and #122), out of five residents observed. Specifically, 1. For Resident #66, Nurse #1 administered the wrong dose of Vitamin D3. 2. For Resident #106, Nurse #6 administered the incorrect medication (Banatrol Plus instead of Juven) and Nurse #6 administered the incorrect dose of a medication (Psyllium). 3. For Resident #122, Nurse #7 administered a medication (Sevelamer Carbonate) after a meal, not according to the manufacturer's recommendations. Findings Include: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain accurate medical records for four Residents (#44 ,#80, #106 and #115), out of a total sample of 30 residents. Specifically, 1. For Resident #44, the facility failed to accurately document they completed a physician ordered treatment when they did not. 2. For Resident #80, the facility failed to accurately document his/her cast care when the cast was no longer there. 3. For Resident #106 the facility failed to ensure nursing maintained a complete record of blood pressures for midodrine administration. 4. For Resident #115, the facility failed to accurately document the location of blood pressure readings.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide a dignified existence for one Resident (#68) out of a total sample of 30 residents.

Inspectors wroteBased on record review and interview, the facility failed to file a grievance for one Resident (#111), out of a total sample of 30 residents. Specifically, the facility staff failed to ensure the Administrator filed a grievance on behalf of Resident #111's who expressed a complaint of staff sleeping on the night shift.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure physician orders were implemented for three Residents (#44, #80, and #102) out of a total sample of 30 residents. Specifically, 1. For Resident #44, the facility failed to complete a treatment to his/her left great toe per physician order. 2. For Resident #80, the facility failed to obtain a physician order for the use of his/her boot immobilizer. 3. For (a) Resident #80 and (b) Resident #102, the facility failed to obtain weekly weights per physician order.

Inspectors wroteBased on record review and interview, the facility failed to provide treatment and care in accordance with professional standards of practice for one Resident (#381), out of a total sample of 30 residents. Specifically, the facility failed to follow physician orders to obtain daily weights and failed to notify a physician or nurse practitioner of a potential significant weight gain as indicated in the physician's orders for a resident with a diagnosis of liver cirrhosis (late stage liver disease, in which healthy liver tissue has been gradually replaced with scar tissue, causing symptoms such as swelling in the legs, feet, or ankles).

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure nursing implemented interventions for pressure ulcer care for one Resident (#119) out of a total sample of 30 Residents. Specifically for Resident #119 who had an actual pressure injury the facility failed to ensure that nursing implemented interventions including an air mattress and Prevalon boots (heel booties, a cushioned bottom that floats the heel off the surface of the mattress, helping to reduce pressure).

Inspectors wroteBased on record review and interviews, the facility failed to adequately maintain the nutrition and hydration status of one Resident (#102) out of a total sample of 30 residents. Specifically, for Resident #102, who had a recent significant weight loss, the facility failed to have the Resident assessed by the dietitian for further interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and maintenance of a Peripherally Inserted Central Catheter (PICC: a flexible tube inserted through a vein in one's arm and passed through to the larger veins near the heart, used to deliver medications intravenously [IV] ), consistent with professional standards of practice for two Residents (#232 and #381), out of a total sample of 30 residents. Specifically, 1. For Resident #232, the facility failed to ensure nursing changed the PICC line dressing with a transparent dressing as ordered. 2. For Resident #381, the facility failed to ensure that when a PICC line dressing was lifting (compromised), it was changed or reinforced and failed to change the PICC line dressing as indicated in the physician's orders on 3/8/25.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure one Resident (#232) was free from significant medication errors, out of a total sample of 30 residents. Specifically, for Resident #232 nursing failed to discontinue an order for Vancomycin HCl Oral Suspension (medication used to treat infections) when this brand was no longer covered by the insurance company, subsequently nursing obtained a different order under a different brand name of Vancomycin (Firvanq Oral Solution Reconstituted), which resulted in nursing administering both orders of Vancomycin (four times daily instead of twice daily).

Inspectors wroteBased on observation and interview, the facility failed to properly adhere to food handling practices to prevent the risk of foodborne illness in accordance with professional standards for food service safety.

Inspectors wroteBased on observation and interview, 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 potential transmission of communicable diseases and infections. Specifically, 1. The facility failed to ensure Nurse #6 disinfected shared resident equipment between resident use. 2. The facility failed to ensure Nurse #9 disinfected shared resident equipment between resident use.

Inspectors wroteBased on observations and interviews, the facility failed to provide a dignified dining experience to the residents of the 2 [NAME] unit. Review of the facility policy titled Assistance with Meals undated, indicated the following: * Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: not standing over residents while assisting them meals.

Inspectors wroteBased on observation, record reviews and interviews the facility failed to ensure sufficient staffing levels were maintained to provide the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, 1) staffing levels were not provided in accordance with the facility's PPD (per patient day) level and facility assessment, and 2) failed to ensure Activities of Daily Living were provided in accordance to one Resident's (#53) plan of care out of a total sample of 29 residents. Review of the facility assessment, not dated, indicated the following: 'Staffing Guidelines' Our facility has created a staffing pattern to ensure that our residents' needs are met on a consistent basis. Our staffing pattern provides a base to ensure that the facility has a sufficient number of qualified staff to meet the needs of the residents. [...]

Inspectors wroteBased on observation, interview and test tray results, the facility failed to serve food that is palatable, and at a safe and appetizing temperature, on three out of three units tested.

Inspectors wroteBased on observation, interview and facility policy review, the facility failed to ensure staff followed proper sanitation and food handling during meal service to prevent the potential outbreak of foodborne illness.

Inspectors wroteBased on observations, interviews and record review for one Resident (#115) out of 29 sampled residents, the facility failed to provide the necessary services to ensure Resident #115 was able to effectively communicate his/her needs.

Inspectors wroteBased on observation, record review and interview the facility failed to identify and investigate bruises of unknown origin for one Resident (#62) out of a total sample of 29 residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to 1) ensure medications were stored as required for one Resident (#2), out of a total sample of 29 residents and 2) ensure medication carts were locked and medications were properly stored when the medication carts were unattended on two of four units.

Inspectors wroteBased on record review and interview, the facility failed to ensure Minimum Data Set (MSD) assessments were accurately completed to reflect the status of two Residents (#36 and #547), out of a total sample of 29 residents. Specifically, 1.) For Resident #36, the facility failed to accurately document that the Resident was determined to meet the criteria for a serious mental illness on a level II Preadmission Screening and Resident Review (PASRR), which is an evaluation to confirm that a Resident has a mental illness or intellectual disability in the MDS assessment. 2.) For Resident #547, the facility failed to accurately document the presence of IV (intravenous) access (a tube that is inserted into the vein to deliver fluids or medications) and administration of IV medications in the MDS assessment.