Brentwood Terrace Healthcare and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, widespreadF725Mar 2, 2024

  Based on interview and record review, the facility failed to provide sufficient number of nursing staff on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans and the facility assessment for 9 of 24 residents (Residents #9, #4, #41, #36, #44, #57, #130, #180, and #179 and 1 of 1 facility reviewed for care and services. The facility failed to provide sufficient nursing staff to ensure adequate supervision and to prevent accidents involving Resident #44, who was physically assaulted on [DATE], Resident #4, had an unwitnessed fall on [DATE], Resident #4 was left unsupervised in the bathroom on [DATE] and self-transferred from the toilet to the wheelchair, Resident 180, sustained an unwitnessed fall with injury on [DATE] and expired on [DATE], and… […]

• Immediate jeopardy, widespreadF835Mar 2, 2024

  Based on interview, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable well-being of each resident for 1 of 1 facility reviewed for administration. The facility administration failed to ensure adequate staff were available and aware of job functions to provide for residents needs when the facility's Administrator position experienced 4 changes within 6 months. The facility failed to ensure the DON was aware that she was the abuse coordinator in absence of the Administrator, and she did not report, investigate or prevent further incidents of abuse per the facility's policy. […]

• Immediate jeopardy, patternF600Mar 2, 2024

  Based on observation, interview, and record review, the facility to ensure the right of the residents to be free from abuse and neglect 7 of 11 residents reviewed for abuse and neglect. (Resident #'s 44, 55, 41, 47, 52, 179 and 36) The facility failed to ensure Resident #44 was protected from Resident #41 after an alleged resident to resident assault resulting in Resident 44 being sent to a local emergency. Resident #44 was assessed with a head contusion (bruise) and a hematoma (a collection of blood outside of the vessel) when she was left alone with her alleged assailant Resident #41. The facility failed to ensure Resident #55 was not left alone with Resident #41 after he allegedly assaulted Resident #44. […]

• Immediate jeopardy, patternF607Mar 2, 2024

  Based on observation, interview, and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, and misappropriation of resident property and establish policies and procedures to report and investigate such allegations for 8 of 11 residents (Resident #'s 44, 55, 41, 47, 52, 179, 57 and 36) reviewed for abuse and neglect. The facility failed to report and investigate when Resident #44 was found to have a large purple bruise to her inner thigh and a fractured hip. The facility failed to ensure Resident #44 was protected from Resident #41 after a resident to resident assault allegation resulting in Resident # 44 being sent to a local emergency room . […]

• Immediate jeopardy, patternF689Mar 2, 2024

  Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 4 of 11 residents (Resident #'s 4, 44, 130, and 180) reviewed for accidents. The facility failed to ensure Resident #44 was provided with adequate supervision when she was physically assaulted by Resident #41 on [DATE]. The facility failed to ensure Resident #4 who required 1 person assistance with toileting was provided adequate supervision to prevent an unwitnessed fall on [DATE] at 10:30 p.m. The facility failed to ensure Resident #4 was not left unsupervised on the toilet on [DATE] and was able to self-transfer between the toilet and the wheelchair. […]