Brethren Village

In the surveyor’s words

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

• Immediate jeopardy, patternF689Apr 27, 2021

  Based on observation, review of facility policy, and staff interviews, it was determined that the facility failed to ensure the food temperature policy included parameters identifying safe beverage temperatures for hot liquids resulting in actual harm to one resident who sustained [CONDITION(S)] on the anterior and lateral right thigh. This resulted in an Immediate Jeopardy situation when it was determined that the policy failed to identify hot beverage temperature parameters which had the potential to cause the residents discomfort or pain, to jeopardize the health and safety of 27 residents of 102 total skilled nursing residents. […]

• Actual harm, isolatedF600Aug 26, 2025

  Based on review of facility policy and procedure, clinical record, facility documentation, and staff interviews, it was determined the facility failed to ensure that one of three residents reviewed were free from neglect during care resulting in actual harm causing a subcapital humeral fracture for Resident 1. Findings include: Review of facility policy titled Freedom from Abuse, Neglect, and Exploitation, last revised October 2024, revealed neglect is the failure of the facility, its Team Members or service providers to provide care, goods, or services to a Resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. […]

• Actual harm, isolatedF600Feb 6, 2025

  Based on review of facility policy, clinical records, hospital records, and staff interviews, it was determined the facility failed to provide necessary services of consistent wound treatment and ensure correct wound medication was applied to an unstageable wound (obscured full-thickness skin and tissue loss). The failure caused actual harm to Resident CL1 when the wound deteriorated and become infected resulting in hospitalization and unnecessary pain for one of three residents reviewed. (Resident CL1) Findings include: Review of the facility's policy titled Freedom from Abuse, Neglect, and Exploitation last revised in [DATE], revealed, facility is committed to interacting with and treating its Residents with dignity and respect. […]

• Actual harm, isolatedF686Feb 6, 2025

  Based facility policy review, clinical record review, hospital record review, facility documentation review, and staff interviews, it was determined that the facility failed to provide consistent and appropriate treatment for an Unstageable Pressure Ulcer (obscured full-thickness skin and tissue loss), resulting in wound deterioration, infection, and hospitalization for one of three residents reviewed (Resident CL1). Findings include. Review of the facility's policy titled Skin Care/Integrity, last revised in February 2024, revealed that the facility's policy is to identify residents at risk for impairment in skin integrity, initiate appropriate preventative interventions, and provide treatment to promote healing, prevent infections, and prevent the development of pressure ulcers. […]

• Actual harm, isolatedF600Apr 6, 2023

  Based on clinical records, facility documentation review, and resident and staff interview, it was determined that the facility failed to ensure that the resident was free from neglect by not providing two-person assistance needed during transfers or providing the proper equipment during a transport for two of 32 residents reviewed (Residents 14 and 91) causing actual harm to Resident 14. Findings Include: Review of Resident 14's diagnosis list included a diagnosis of intracranial hemorrhage (stroke) and Hemiplegia non-dominate left side (inability to move one side of the body). Review of Resident 14's care kardex revealed as of January 30, 2023 Resident 14 was to have the foot pedals of the wheelchair removed while in the room as resident prefers to self-propel independently when in room. […]