Brendan House

In the surveyor’s words

From the most serious findings on record at Brendan House, in the surveyor’s own words.

• Actual harm, isolatedF692Jul 17, 2025

  Based 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. Findings include:1. During an interview on 7/16/25 at 3:13 p.m., staff member D stated all physicians were notified when a resident was brought to NAR (Nutrition at Risk). Staff member D stated she could not write nutrition orders, but she could order supplements. Staff member D stated weights were supposed to be obtained the first weekend of the month. Staff member D stated she pulled reports on resident weights the following week. Staff member D stated the staff also sent a message if the resident had weight loss. […]

• Actual harm, isolatedF686Sep 14, 2023

  Based 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. Findings include: During an observation on 9/12/23 at 9:28 a.m., resident #62 was in his bed in low fowler's position (head slightly elevated), with no positioning devices or pillows except one pillow under his head. During an observation at 9/12/23 at 2:08 p.m., resident #62 was in his bed in low fowler's position, with no positioning devices or pillows except one pillow under his head. […]

• Actual harm, isolatedF692Sep 14, 2023

  Based 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. […]

• Actual harm, isolatedF600Dec 22, 2022

  Based on interview and record review, the facility failed to keep a resident free from abuse, resulting in the resident feeling belittled and ashamed, for 1 (#49) of 3 sampled residents. Findings include: During an interview on 12/20/22 at 9:02 a.m., resident #49 stated she had an issue, back in October 2022, with NF1. Resident #49 stated one morning she woke up, and she was soaked with urine, after having an incontinence episode. Resident #49 stated NF1 was rude and curt with her, and told the resident, Anyone can feel when they have to go to the bathroom, why didn't you go last night? You are a grown woman. You are thoroughly disgusting, and you stink. I would rather have someone else to take care of today. Resident #49 stated this made her feel belittled and ashamed. […]

• No harm, potential for more than minimal, widespreadF880Jul 30, 2026

  Based on observation, interview, and record review the facility failed to ensure staff properly followed EBP (Enhanced Barrier Precautions), maintained a clean environment with urinal care and used proper hand hygiene for 4 (#s 12, 33, 42, and 54) out of 4 residents sampled for resident care observations; failed to ensure staff used proper hand hygiene during the medication pass for 1 (#85) out of 1 resident observed; failed to ensure staff properly cleaned the glucometer for 2 (#s 20 and 55) out of 2 residents observed for blood glucose measurements; and failed to review vaccine and infection control policies annually. This deficient practice increased the likelihood of spreading infection. Findings include:1. […]