Brentwood Health Care Center

In the surveyor’s words

From the most serious findings on record at Brentwood Health Care Center, in the surveyor’s own words.

• Actual harm, isolatedF600Jul 9, 2024

  Based on record review and interview, the facility failed to ensure Resident #6 and Resident #50 were free from resident to resident sexual abuse. This affected two residents (#6 and #50) of three residents reviewed for abuse. Actual physical and/or psychosocial harm, applying the reasonable person concept, occurred on 06/05/24 to Resident #50, a resident with impaired cognition, when Resident #101 who had a history of sexually inappropriate behaviors without care planned interventions in place, placed his hand down Resident #50's incontinence brief (an incident of sexual abuse). Following the incident, Resident #6 was visibly crying and shaking with a noted change by family on 06/06/24. Findings include: 1. […]

• No harm, potential for more than minimal, patternF880Jul 24, 2025

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure personal protective equipment (PPE) was worn for Enhanced Barrier Precaution (EBP) during medication administration via percutaneous endoscopic gastrostomy (PEG) tube for Resident #83. This affected one (Resident #83) five residents reviewed for medication administration had the potential to affect all residents on Registered Nurse (RN) #509's assignment, who had EBP's to include (Residents #3, #12, #35, and #36). The facility failed to ensure infection control was maintained during perineal care for Resident #94. […]

• No harm, potential for more than minimal, isolatedF641Jul 24, 2025

  Based on record review and staff interview, the facility failed to accurately code the preadmission screen and resident review (PASRR) status on the Minimum Data Set (MDS) 3.0 assessment for Residents #43 and #82. This affected two (Residents #43 and #82) of three residents identified by the facility as having a level two mental illness and/or an intellectual disability. The facility census was 80.Findings include:1. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, schizophrenia and depression. […]

• No harm, potential for more than minimal, isolatedF583Nov 12, 2024

  Based on interview, review of a self-reported incident (SRI), record review and review of the facility policies, the facility failed to ensure residents were free from unauthorized video recordings by staff. This affected one resident (#4) of three residents reviewed for abuse. The facility census was 88. Findings include: Review of Resident #4's medical record revealed an admitted [DATE] and diagnoses including Alzheimer's disease, type II diabetes, dementia with other behavioral disturbance, depression, anxiety, and adult failure to thrive. Review of Resident #4's quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 had short and long term memory problems and severe cognitive impairment with continuous inattention and disorganized thinking. […]

• No harm, potential for more than minimal, isolatedF580Jul 9, 2024

  Based on record review and interviews, the facility failed to report a change in condition to Resident #50's responsible party and physician, when the resident was sexually abused and was agitated and crying. This affected one resident (Resident #50) of three residents reviewed for notification of change in condition. Findings include: Review of Resident #50's open medical record revealed the resident was admitted on [DATE] with diagnoses including Parkinson's disease with dyskinesia, unspecified dementia and anxiety disorder. Review of Resident #50's Admission MDS 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. […]