Brush Country Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Brush Country Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF697Oct 4, 2025

  Based on observation, interviews and record review, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of three residents reviewed for pain. The facility failed to provide effective pain interventions for Resident #1 on 09/14/2025. Resident #1 called for emergency transfer to the ER for pain management. An IJ was identified on10/03/2025. The IJ template was provided to the facility on [DATE] at 12:34 pm. […]

• Immediate jeopardy, patternF686May 7, 2025

  Based on observation, interview, and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for one (Resident #1) of five residents reviewed for pressure injuries. The facility failed to: - Complete weekly skin assessments for Resident #1 or provide treatments from 04/18/25 - 05/06/25 to a pressure area on his left foot which developed into a pressure wound. - Provide wound care consistently to Resident #1's sacral wound causing it to worsen. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 05/06/25 at 4:54 PM, and an IJ template was given. […]

• Immediate jeopardy, isolatedF684Sep 11, 2021

  Based on interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for three (Resident #1, Resident #2, and Resident #6) of 19 residents reviewed for quality of care, in that: A.) The facility failed to ensure that R1 with physical debilities and severe cognitive impairment was checked on as needed throughout the night shift as she was found with active ants crawling on her while she was in bed with ant bites throughout her body causing resident pain, red welts, and hives that required immediate medical intervention and treatment. […]

• Actual harm, isolatedF690Feb 26, 2024

  Based on interview and record review, the facility failed to provide a resident with urinary incontinence appropriate treatment and services to prevent urinary tract infections for 1 of 3 residents reviewed for urinary catheters (Resident #1) in that, RN A failed to transcribe Resident #1's foley catheter order correctly and LVN B did not insert Resident #1's foley catheter according to physician orders and Resident #1 was sent to the local hospita ER, was admitted in ICU for sepsis after experiencing a change of condition on 02/04/2024. This failure could place residents with indwelling catheters at risk for infections, discomfort, and sepsis . Findings included: Review of Resident #1's undated face sheet revealed a 67-year- male with admitted [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Aug 21, 2025

  Based on observations, interviews, and record review the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's only kitchen and the facility's only nourishment room reviewed for food and nutrition services. 1. The facility failed to label and date food items in the only walk-in refrigerator. 2. The facility failed to label and date food items in the only nourishment refrigerator.3. The facility failed to maintain the proper temperature of the refrigerator in the nourishment room.4. The facility failed to ensure that the walk-in freezer was maintained at acceptable temperatures which resulted in frozen foods thawing out and then re-freezing without being discarded. 5. […]