Brickyard Healthcare - Brentwood Care Center

In the surveyor’s words

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

• Actual harm, isolatedF689Apr 5, 2021

  Based on record review and interview, the facility failed to implement adequate supervision and specific interventions for 1 of 3 residents who was identified as a fall risk. Resident E had an unwitnessed fall that resulted in a laceration to the forehead that required sutures and a cervical (C5) fracture. (Resident E) Findings include: During a review of Resident E's clinical record on 3/29/21 at 2:11 p.m., it indicated Resident E's diagnoses included, but were not limited to, [CONDITION(S)], stage 2, hypertension, non-Alzheimer's dementia, [CONDITION(S)], primary [CONDITION(S)]. Resident E's Quarterly MDS (minimum data set), dated 2/16/21, indicated Resident E had severe cognitive impairment. […]

• No harm, potential for more than minimal, patternF761Feb 25, 2025

  Based on observation, interview, and record review, the facility failed to ensure medications were properly dated, labeled, and not expired for 1 of 4 medication carts, and 2 of 2 medication storage rooms reviewed for medication storage. (400 Hall Medication Cart, North Hall Medication Storage Room Refrigerator, South Hall Medication Room with Refrigerator) Findings include: On 2/20/25 at 10:00 A.M., the following undated medications were observed in the 400 Hall Medication Cart: 1 Humalog Insulin pen for [Patient Name] with no open date On 2/24/25 at 9:10 A.M., the following expired medications were observed in the North Hall Medication Storage Room Refrigerator: 1 bottle of Mary's Medical Mouth Wash for [Resident Name] with an expiration date of 1/15/25 On 2/24/25 at 10:16 A.M., the… […]

• No harm, potential for more than minimal, patternF761Jan 23, 2024

  Based on observation, record review, and interview, the facility failed to provide proper storage of medications and personal property in 3 of 5 medication carts reviewed. Loose pills, unlabeled medications, and resident's personal property were found in medication drawers and the narcotic box of medication carts. (200 Hall, 500 Hall, Alzheimer Unit) Findings include: 1. On 1/18/24 at 8:38 A.M., the upper drawer of the tan cart on the 200 hall was observed to have the following unlabeled medications: 1 box of antihistamine lacked a name and label. 1 box of antihistamine with [patient name] lacked a label. 1 bottle of acetaminophen with [patient name] lacked a label. 2. […]

• No harm, potential for more than minimal, patternF804Jan 23, 2024

  Based on observation, interview, and record review, the facility failed to ensure food was served at a palatable temperature for 1 of 1 tray tested for food temperature. Finding includes: On 1/16/24 at 11:30 A.M., Resident 79 indicated the food was not hot enough. On 1/16/24 at 11:38 A.M., Resident 1 indicated the food was cold. She lived in the last room served on her hall. On 1/18/24 at 12:03 P.M., 2 Certified Nursing Aides (CNA) were observed delivering meal trays on the 500 hallway. All but 4 trays were in a large, insulated cart. The other 4 trays were on a small pushcart, not insulated. At that time, CNA 11 indicated the larger insulated cart was too small to hold all the trays for the hall. On 1/18/24 at 12:15 P.M., a test tray was obtained from the 500 hallway. […]

• No harm, potential for more than minimal, patternF812Jan 23, 2024

  Based on observation, interview, and record review, the facility failed to store foods in accordance with professional standards and maintain the dishwasher with the proper equipment for 1 of 1 kitchens reviewed. Findings include: 1. On [DATE] at 10:20 A.M., a tour of the kitchen began. Two staff were present, a cook and the dishwasher. On [DATE] at 10:35 A.M., food packages were observed in the walk-in refrigerator labeled with a date in black marker. None of the marked dates differentiated between open date and use-by date. […]