Brentwood Health Center

In the surveyor’s words

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

• Actual harm, patternF692May 22, 2023

  Based on record review and staff interview, it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight or protein levels for 4 of 10 residents reviewed for nutrition, Resident ID#s 12, 65, 72, and 74. Findings are as follows: Record review of the State Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities, revised on 2/3/2023, reveals a weight loss of 5% in 1 month, 7.5% in 3 months, and 10% in 6 months is significant weight loss. Additionally, greater than 5% in 1 month, greater than 7.5% in 3 months, and greater than 10% in 6 months is severe weight loss. […]

• Actual harm, isolatedF686Apr 21, 2026

  Based on surveyor observation, clinical record review, and staff interviews, the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent pressure ulcers for 1 of 1 resident reviewed, Resident ID #3. Specifically, the resident was left on a bedpan for an undetermined length of time, resulting in prolonged, unrelieved pressure and the worsening of an existing pressure ulcer, as well as the development of a new pressure ulcer. […]

• Actual harm, isolatedF760Oct 12, 2022

  Based on record review and resident and staff interview it has been determined that the facility failed to ensure that its residents are kept free from significant medication errors for 1 of 4 residents reviewed for medication administration, Resident ID #3. Findings are as follows: Record review revealed the resident was admitted to the facility in May of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a facility Adverse Event Report stated in part, This resident has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On Friday afternoon (10/7/22), [S/he] received the incorrect eye solution and was instead given Covid Reagent drops [liquid reagent used as a preservative that triggers a chemical reaction to determine if the test is positive or negative] in both eyes. […]

• Actual harm, isolatedF600Jun 14, 2022

  Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to protect the resident's right to be free from sexual abuse for 2 of 4 residents reviewed, Resident ID's #2 and 3. Findings are as follows: Record review of facility reported complaint that was submitted to the Department of Health on 6/11/2022 indicated a Licensed Practical Nurse (LPN), Staff A, witnessed Resident ID #1, inappropriately touching his/her roommate, Resident ID #2. Review of the employee training titled: Abuse Neglect and Exploitation Defines sexual abuse as the non-consensual sexual contact of any kind with a resident. Sexual contact with any person incapable of giving consent is also considered sexual abuse. […]

• No harm, potential for more than minimal, widespreadF812Jul 25, 2025

  Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety relative to the main kitchen and for one of two kitchenettes.Findings are as follows:1. The Rhode Island Food Code 2022 Edition 4-601.11 states in part, .nonfood contact surfaces of equipment shall be kept from an accumulation of dust, dirt, food residue and other debris.During surveyor observations of the main kitchen on 7/22/2025 at 8:50 AM and 7/24/2025 at 10:57 AM revealed the following:-the walls behind the dish machine, stove and worktables were observed to have an accumulation of food spills/splatters -Formica topped food carts were observed to have chips in the… […]