Brentwood Rehabilitation and Healthcare CTR (The)

In the surveyor’s words

From the most serious findings on record at Brentwood Rehabilitation and Healthcare CTR (The), in the surveyor’s own words.

• Actual harm, isolatedF600Jul 13, 2022

  Based on interviews and records reviewed, for three of three sampled residents (Resident #1, #2, and #3), the Facility failed to ensure the residents were free from sexual abuse by a staff member. During the overnight shift beginning on 06/24/22, Resident #1, who was alert and oriented, called 911 (from the Facility) to report he/she had been sexually assaulted by a male staff member (later identified as Nurse Aide (NA) #1). During the course of the Facility and local law enforcement investigations, Resident #2 and Resident #3, also alert and oriented residents, reported they had been sexually assaulted by a male staff member (later identified as NA #1), during the same overnight shift beginning on 06/24/22. […]

• No harm, potential for more than minimal, widespreadF585Mar 25, 2021

  Based on record review and interview the facility staff failed to (1.) make information available on how to file a grievance or complaint to the residents and (2.) failed to maintain postings in prominent areas throughout the facility regarding the resident's right to file grievances in writing on 4 of 4 resident units. Findings include: The facility policy titled Grievances/Complaints, dated November 2017, indicated the following: 1.) The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. […]

• No harm, potential for more than minimal, patternF759Mar 13, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF842Mar 13, 2025

  Based 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. Findings include: 1. […]

• No harm, potential for more than minimal, patternF550Mar 28, 2024

  Based 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. Findings include: On 3/26/23 at 8:00 A.M., the surveyor observed following on the 2 [NAME] unit: *There were five residents sitting at a table. The first resident was served his/her meal at 8:12 A.M. The last resident was served his/her meal at 8:40 A.M., 28 minutes later. *There were four residents sitting at a table. The first resident was served his/her meal at 8:08 A.M. […]