Deficiencies (last 3 years)
Deficiencies (over 3 years)
23.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
585% worse than Rhode Island average
Rhode Island average: 3.4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
92% occupied
Based on a July 2025 inspection.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 2, 2025
Visit Reason
An off-site desk audit was conducted to review all previous deficiencies cited on 7/25/2025 and verify corrective actions.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Census: 88
Capacity: 96
Deficiencies: 6
Date: Jul 25, 2025
Visit Reason
The document is a Plan of Correction (POC) submitted by Brentwood Health Center following a recertification and complaint surveys conducted from 7/22/2025 through 7/25/2025 to address identified deficiencies and demonstrate compliance with federal regulations.
Findings
Deficiencies were identified related to notification of changes in resident condition, professional standards of care, quality of care, food safety, nursing services, and environmental conditions. The facility failed to notify physicians timely, ensure proper documentation and follow-up, and maintain food safety standards among other issues.
Deficiencies (6)
Failure to immediately inform the resident's physician and notify the resident representative of changes in condition requiring physician intervention.
Failure to meet professional standards of care related to oxygen utilization and weight monitoring.
Failure to provide quality of care including timely notification of changes in condition and fall prevention.
Failure to provide appropriate treatment and services for urinary incontinence.
Failure to ensure food safety and sanitation in the main kitchen and food service areas.
Failure to maintain a safe, functional, sanitary, and comfortable environment for residents and staff.
Report Facts
Census: 88
Total Capacity: 96
Date of Survey: Jul 25, 2025
Deficiency Count: 6
Inspection Report
Annual Inspection
Census: 88
Capacity: 96
Deficiencies: 8
Date: Jul 25, 2025
Visit Reason
A recertification and complaint surveys were conducted at Brentwood Health Center from 7/22/2025 through 7/25/2025 to determine compliance with 42 C.F.R. Part 483, requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were identified as a result of the survey, including failures to immediately notify the resident's physician of a significant change in condition, failure to meet professional standards of care, failure to monitor and document weight discrepancies and orthostatic blood pressures, inadequate quality of care related to oxygen administration and fall risk, failure to provide appropriate bowel and bladder care, insufficient nursing staff competencies, and food safety violations. No life safety code deficiencies were identified.
Deficiencies (8)
Failure to immediately notify the resident's physician of a significant change in condition resulting in transfer to acute care hospital.
Failure to ensure services provided meet professional standards of quality for multiple residents.
Failure to monitor and document orthostatic blood pressures and weight discrepancies as per facility policy and physician orders.
Failure to provide necessary treatment and care in accordance with professional standards related to oxygen administration and fall risk.
Failure to provide appropriate bowel and bladder care and treatment for residents with incontinence and constipation.
Failure to ensure nursing staff have appropriate competencies and skills to provide care and identify changes in condition.
Failure to store, prepare, distribute and serve food in accordance with professional standards for food service safety, including unclean equipment and uncovered food trays.
Failure to maintain a safe, functional, sanitary, and comfortable environment related to food trays left in hallways with partially consumed meals.
Report Facts
Census: 88
Total Capacity: 96
Deficiencies cited: 8
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 23, 2025
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to accurately assess residents at risk for elopement and to ensure proper use and monitoring of TekTone elopement prevention devices, following an incident where a resident eloped and sustained a major injury.
Complaint Details
The complaint investigation was triggered by an incident where Resident ID #1 eloped from the facility on 6/12/2025, was found with a large hematoma and a left hip fracture, and it was determined that the facility failed to properly monitor and ensure placement of the TekTone elopement prevention device as ordered. The investigation found failures in transcription of physician orders, monitoring, documentation, and supervision.
Findings
The facility failed to accurately code the use of TekTone elopement prevention bracelets in Minimum Data Set (MDS) assessments for residents at risk. Additionally, the facility failed to ensure proper placement and monitoring of the TekTone device for a cognitively impaired resident who eloped, resulting in a hip fracture. The facility also failed to follow physician orders for checking the device every shift and did not properly document medication administration and device checks.
Deficiencies (3)
Failed to ensure that the Minimum Data Set (MDS) Assessment accurately reflected the resident's status for elopement risk and use of TekTone bracelet.
Failed to ensure that the nursing home area was free from accident hazards and provided adequate supervision to prevent accidents related to the placement and monitoring of a TekTone device, resulting in a resident eloping and sustaining a major injury.
Failed to safeguard resident-identifiable information and maintain complete and accurate medical records related to monitoring of the TekTone elopement prevention device for a resident who eloped and sustained a hip fracture.
Report Facts
Deficiencies cited: 3
Resident Brief Interview for Mental Status (BIMS) score: 6
Date of incident: Jun 12, 2025
Date of survey: Jun 23, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Authored progress note about resident found outside; admitted resident did not have TekTone device on |
| Staff B | Nursing Assistant | Unable to recall if resident had TekTone device during evening rounds |
| Staff C | Nursing Assistant | Discovered resident outside and alerted staff |
| Director of Nursing Service | Director of Nursing Service | Acknowledged failure to provide evidence of TekTone device checks and uncertainty about exit door |
| Nurse Practitioner | Nurse Practitioner | Reported resident had taken off TekTone device two weeks prior and expected staff to check device every shift |
| MDS Coordinator | MDS Coordinator | Acknowledged inaccurate coding of TekTone device in MDS assessments |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 6, 2025
Visit Reason
The inspection was conducted following a community reported complaint submitted to the Rhode Island Department of Health on 2025-05-05 regarding Resident ID #1's abdominal pain and bruising.
Complaint Details
The complaint alleged Resident ID #1 was complaining of abdominal pain and was observed with large purple bruising extending from upper chest to upper abdomen. The investigation found failure to complete and document required weekly skin evaluations as ordered.
Findings
The facility failed to meet professional standards of quality for 2 of 3 residents reviewed related to physician's orders for weekly skin evaluations. Weekly skin assessments were signed off as completed but lacked documented evidence in the observations and progress notes.
Deficiencies (2)
Failure to complete and document weekly skin evaluations for Resident ID #1 as ordered by the physician.
Failure to complete and document weekly skin evaluations for Resident ID #3 as ordered by the physician.
Report Facts
Residents reviewed: 3
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | Interviewed on 2025-05-06 and unable to provide evidence that weekly skin assessments were completed as ordered |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 25, 2025
Visit Reason
The inspection was conducted in response to a community reported complaint submitted to the Rhode Island Department of Health on 2025-03-19 alleging that Resident ID #1's medical needs had not been met.
Complaint Details
Complaint was submitted on 2025-03-19 alleging unmet medical needs for Resident ID #1. The complaint was substantiated based on record review and staff interviews.
Findings
The facility failed to accurately maintain the resident's medical record and medication administration in accordance with accepted professional standards. Specifically, both the 25 mg and 37.5 mg doses of Spironolactone were documented as administered on the same day, though staff denied administering the 25 mg dose. Additionally, physician orders for tucks pads and twice daily blood pressure assessments were not transcribed or completed, and there was no evidence these treatments were provided.
Deficiencies (2)
Failure to accurately maintain resident's medical record and medication administration, including administration of two doses of Spironolactone on the same day.
Physician orders for tucks pads and twice daily blood pressure assessments were not transcribed or completed, and treatments were not provided as ordered.
Report Facts
Medication doses administered: 2
Duration of blood pressure assessment order: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Authored progress notes and acknowledged documentation and transcription failures |
| Staff B | Nurse Practitioner (NP) | Prescribed medication dose increase and new orders |
| Staff C | Registered Nurse | Acknowledged failure to transcribe and complete physician's order for blood pressure assessment |
| Administrator | Acknowledged expectation to discontinue incorrect medication and initiate correct order; unable to provide evidence of accurate documentation or transcription |
Inspection Report
Routine
Deficiencies: 10
Date: Mar 12, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, food safety, staff training, and quality assurance at Sunny View Nursing Home.
Findings
The facility was found deficient in multiple areas including failure to provide required Medicare/Medicaid notices to residents, failure to notify residents of bed-hold policies, inadequate assistance with activities of daily living, failure to follow physician orders for bowel care, delayed pressure ulcer treatment, lack of annual performance reviews for nurse aides, medication errors related to missed Victoza injections, food safety violations including improper labeling and temperature control, and failure to maintain an effective quality assurance program and staff training.
Deficiencies (10)
Failed to provide Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to 4 of 5 residents discharged with Medicare Part A Services.
Failed to provide written bed hold notification upon hospital transfer for 1 of 2 residents reviewed.
Failed to assist 1 resident with shaving, impacting activities of daily living.
Failed to implement bowel protocol orders for 1 resident, resulting in prolonged constipation.
Failed to provide timely treatment for a stage 3 pressure ulcer for 1 resident.
Failed to complete annual performance reviews for 4 nurse aides.
Failed to ensure resident was free from significant medication errors; missed Victoza injections for 1 resident.
Failed to store, prepare, distribute, and serve food in accordance with professional standards including unlabeled and undated food items and improper hot holding temperatures.
Failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program with measurable objectives and tracking.
Failed to provide required annual training for 8 of 10 employees on abuse, infection control, and dementia management.
Report Facts
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Nurse aides: 4
Employees: 8
Elevated blood sugar: 540
Elevated blood sugar: 416
Food temperature: 102
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Nursing Assistant | Acknowledged should have assisted resident with shaving |
| Staff B | Registered Nurse | Acknowledged resident's facial hair and that shaving is part of resident care |
| Staff D | Registered Nurse | Unable to provide evidence bowel protocol orders were administered |
| Staff I | Licensed Practical Nurse | Did not notify provider that Victoza was unavailable |
| Staff J | Dietary Cook | Acknowledged broccoli was below safe hot holding temperature |
| Food Service Director | Food Service Director | Acknowledged food and beverages should be labeled and dated when opened |
| Administrator | Administrator | Acknowledged failure to provide SNFABN forms, bed hold notification, and lack of QAPI tracking and staff training |
| Director of Nursing Services | Director of Nursing Services | Acknowledged bowel protocol orders not implemented, delayed pressure ulcer treatment, missed Victoza doses, and shaving assistance failure |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 15, 2025
Visit Reason
The inspection was conducted following a community reported complaint alleging that Resident ID #1 was not receiving appropriate care at the facility, specifically regarding failure to provide scheduled weekly showers to residents.
Complaint Details
The complaint was community reported to the Rhode Island Department of Health on 2025-01-10 alleging inadequate care for Resident ID #1, specifically missing scheduled showers. The complaint was substantiated by surveyor observations, record reviews, and staff interviews.
Findings
The facility failed to provide necessary care related to weekly scheduled showers for 4 of 4 residents reviewed. Multiple residents reported missing showers, and the facility lacked documentation verifying that scheduled showers were provided. Staff interviews confirmed that showers were scheduled once a week but were not consistently given or documented.
Deficiencies (1)
Failure to provide scheduled weekly showers to residents dependent on staff for activities of daily living.
Report Facts
Scheduled showers missed: 3
Scheduled showers received: 2
BIMS scores: 15
BIMS scores: 13
BIMS scores: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Nursing Assistant | Primary NA for Resident ID #1, interviewed about shower scheduling and documentation |
| Staff B | Nursing Assistant | Interviewed regarding shower frequency and lack of documentation for Resident ID #3 |
| Staff C | Licensed Practical Nurse | Interviewed about shower schedule and documentation practices |
| DNS | Director of Nursing Services | Interviewed regarding lack of evidence for residents receiving scheduled showers and facility documentation practices |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 14, 2024
Visit Reason
A follow-up off-site desk audit and a follow-up Life Safety survey were conducted to verify correction of previous deficiencies cited on July 11, 2024.
Findings
All previous deficiencies have been corrected based on acceptable plans of correction and supporting documentation. No new deficiencies were identified, and the facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 14, 2024
Visit Reason
An off-site desk audit was conducted on August 14, 2024, to review all previous deficiencies cited on July 11, 2024.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 86
Capacity: 96
Deficiencies: 13
Date: Jul 11, 2024
Visit Reason
A Recertification Survey and complaint investigation survey were conducted at Brentwood Nursing Home from 7/9/2024 through 7/11/2024 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness.
Complaint Details
The survey included a complaint investigation as referenced by ACTS Reference Numbers 96263 and 96457. The complaint investigation focused on resident rights, communication barriers, and quality of care issues.
Findings
Deficiencies were cited related to resident rights, notice requirements before transfer/discharge, dialysis care, nurse aide performance review, medication management, food safety, infection control, emergency preparedness, and life safety code compliance. The facility failed to provide adequate communication support for residents with limited English proficiency and failed to maintain proper documentation and procedures in several areas.
Deficiencies (13)
Failure to treat residents with respect and dignity, especially for residents whose primary language is not the dominant language of the facility.
Failure to provide proper notice before transfer or discharge to the Office of the State Long-Term Care Ombudsman for discharged residents.
Failure to ensure residents receiving dialysis receive services consistent with professional standards, including proper documentation and physician orders.
Failure to complete annual performance reviews for nursing assistants.
Failure to ensure residents are free of significant medication errors, including missed insulin doses.
Failure to properly label and store drugs and biologics in locked compartments with proper temperature controls.
Failure to provide residents with suitable nourishing snacks at bedtime.
Failure to prepare, store, and distribute food according to professional standards of food service safety.
Failure to maintain infection prevention and control program to prevent transmission of communicable diseases and multidrug-resistant organisms.
Failure to conduct emergency preparedness exercises and maintain emergency plans as required.
Failure to maintain sprinkler system installation and life safety code compliance.
Failure to maintain electrical systems and emergency power supply in accordance with NFPA standards.
Failure to maintain oxygen cylinders and storage in accordance with fire safety regulations.
Report Facts
Capacity: 96
Census: 86
Dates of survey: Survey conducted from 2024-07-09 through 2024-07-11
Deficiency completion dates: Plan of Correction completion dates mostly 2024-08-10
Resident counts: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Social Worker | Interviewed regarding resident assessments and communication barriers |
| Staff B | Nursing Assistant | Interviewed regarding communication difficulties with resident |
| Staff C | Licensed Practical Nurse | Observed and interviewed regarding resident care and communication barriers |
| Staff E | Occupational Therapy Assistant | Interviewed regarding communication with resident |
| Staff F | Registered Nurse | Interviewed regarding dialysis care and medication administration |
| Staff G | Nursing Assistant | Named in deficiency related to performance evaluations |
| Staff H | Nursing Assistant | Named in deficiency related to performance evaluations |
| Staff I | Nursing Assistant | Named in deficiency related to performance evaluations |
| Staff J | Nursing Assistant | Named in deficiency related to performance evaluations |
| Staff K | Nursing Assistant | Named in deficiency related to performance evaluations |
| Staff L | Licensed Practical Nurse | Interviewed regarding medication administration |
| Staff M | Dietary Cook | Named in deficiency related to food safety manager license |
| Staff N | Housekeeper | Observed during infection control deficiency related to PPE use |
| Staff O | Registered Nurse | Observed performing wound dressing change |
| Director of Nursing | Director of Nursing Services | Responsible for implementing plans of correction and interviewed regarding deficiencies |
| Administrator | Facility Administrator | Interviewed regarding emergency preparedness and food service |
| Maintenance Director | Maintenance Director | Interviewed regarding life safety and sprinkler system deficiencies |
| Interim Regional Maintenance Director | Interim Regional Maintenance Director | Interviewed regarding life safety and sprinkler system deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Mar 25, 2024
Visit Reason
The inspection was conducted as a standard regulatory survey to assess compliance with healthcare regulations and facility standards at Sunny View Nursing Home.
Findings
The facility was found deficient in multiple areas including failure to complete significant change in status assessments for residents admitted to hospice, failure to provide appropriate treatment and care during acute changes in condition, inadequate pressure ulcer care, improper food storage and cooling procedures, failure to maintain an effective infection prevention and control program, and failure to ensure a working call system accessible to residents.
Deficiencies (6)
Failed to complete a significant change in status assessment within 14 days after a significant change in condition for 4 of 5 residents admitted to hospice services.
Failed to provide treatment and care according to professional standards and failed to promptly identify and intervene during an acute change in condition related to vomiting and an unknown cardiac event for 1 resident.
Failed to ensure a resident received care consistent with professional standards to prevent pressure ulcers, resulting in a right heel pressure ulcer.
Failed to properly store and serve food under sanitary conditions, including improper cold holding temperature of tartar sauce and failure to cool foods to 70 degrees F within 2 hours.
Failed to maintain an infection prevention and control program to prevent transmission of communicable diseases during a potential gastrointestinal virus outbreak and failed to follow proper infection control practices during wound dressing changes.
Failed to ensure a working call system was available and accessible to a resident with upper extremity impairment.
Report Facts
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 4
Temperature: 62
Temperature: 50
Temperature: 80
Temperature: 85
Temperature: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Acknowledged failure to complete full assessment and notify physician of resident vomiting |
| Staff B | Nurse Practitioner | Stated expectation that vomiting should be reported and assessed with vital signs |
| Staff C | Registered Nurse | Acknowledged resident's heels were not offloaded as ordered |
| Staff D | Licensed Practical Nurse | Observed failing to follow proper infection control during wound dressing change and acknowledged the error |
| Director of Nursing Services | Director of Nursing Services | Interviewed multiple times acknowledging deficiencies and expectations for compliance |
| Food Service Director | Food Service Director | Acknowledged food temperature violations during inspection |
| Regional Infection Preventionist | Regional Infection Preventionist | Acknowledged failure to initiate line list for GI illness outbreak |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 13, 2023
Visit Reason
The inspection was conducted in response to a community reported complaint alleging that Resident ID #8 sustained a fall on 12/3/2023 and did not receive appropriate medical attention until 12/5/2023. Additionally, the investigation included review of infection prevention and control practices related to a Respiratory Syncytial Virus (RSV) outbreak affecting multiple residents.
Complaint Details
The complaint alleged that Resident ID #8 sustained a fall on 12/3/2023 and did not receive appropriate medical attention until 12/5/2023, specifically a delayed STAT X-Ray. The complaint investigation confirmed the delay and failure to notify the provider of the delay, resulting in prolonged pain for the resident.
Findings
The facility failed to provide timely radiology services for Resident ID #8, delaying a STAT X-Ray after a fall, resulting in prolonged pain. The facility also failed to maintain an adequate infection prevention and control program to prevent the transmission of RSV, leading to an outbreak affecting multiple residents, improper PPE use by staff, incorrect signage, and one resident death.
Deficiencies (2)
Failure to provide timely, approved x-ray services or have an agreement with an approved provider to obtain them, resulting in delayed diagnostic imaging for Resident ID #8 after a fall.
Failure to provide and implement an infection prevention and control program to prevent transmission of RSV, including inadequate PPE use, incorrect signage, and failure to promptly identify respiratory symptoms, affecting multiple residents.
Report Facts
Medication doses: 3
Medication doses: 1
Dates of illness onset: 7
Dates of illness onset: 10
Dates of illness onset: 12
Fever: 102.2
Pulse: 156
Pulse oximetry: 85
Oxygen liters: 4
Fever: 101.5
Pulse oximetry: 88
Oxygen liters: 3
Pulse oximetry: 94
Pulse oximetry: 80
Oxygen liters: 5
Pulse oximetry: 91
Pulse oximetry: 79
Oxygen liters: 4.5
Oxygen saturation: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Interviewed regarding Resident ID #8 fall and failure to report pain to physician. |
| Staff B | Nurse Practitioner (NP) | Authored progress note and ordered STAT X-Ray for Resident ID #8. |
| Staff C | Registered Nurse (RN) | Contacted X-Ray provider regarding STAT X-Ray delay for Resident ID #8. |
| Staff D | Registered Nurse (RN) | Called X-Ray provider on 12/5/2023 regarding delay in STAT X-Ray for Resident ID #8. |
| Director of Nursing Services | Interviewed and acknowledged failure to obtain radiology services and notify provider of delay for Resident ID #8. | |
| Staff E | Certified Nursing Assistant (CNA) | Observed wearing only surgical mask, unable to state precautions for RSV resident. |
| Staff F | Housekeeper | Observed without appropriate PPE per signage for RSV resident. |
| Staff G | Speech Therapist | Observed wearing only surgical mask, failed to wear appropriate PPE for RSV resident. |
| Staff H | Registered Nurse (RN) | Interviewed about proper PPE use for RSV precautions. |
| Staff I | Housekeeper | Observed wearing gown, gloves, surgical mask but no eye protection for RSV resident. |
| Administrator | Present during interview with Director of Nursing Services acknowledging PPE and signage failures. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 29, 2023
Visit Reason
A revisit survey was conducted on June 29, 2023, for all previous deficiencies cited on May 17, 2023, related to the Re-certification/Licensure Life Safety Code survey.
Findings
All deficiencies have been corrected and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 22, 2023
Visit Reason
A follow-up to a previous recertification survey conducted at this facility to verify correction of prior deficiencies.
Findings
All previous deficiencies were corrected and no new deficiencies were identified during this follow-up survey.
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: May 22, 2023
Visit Reason
A Recertification Survey and complaint investigation was conducted at Brentwood Nursing Home from 5/15/2023 through 5/22/2023 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Complaint Details
The survey included a complaint investigation under ACTS Reference Number 90145. Deficiencies were cited as a result of this complaint investigation and recertification survey.
Findings
Deficiencies were cited related to failure to meet professional standards of quality in comprehensive care plans, including incomplete skin integrity observations, improper medication administration, inadequate incontinence care, failure to maintain nutritional status, food safety violations, infection prevention and control issues, and failure to provide adequate training and documentation for staff.
Deficiencies (9)
Failure to meet professional standards of quality in comprehensive care plans, including incomplete weekly skin integrity observations for multiple residents.
Medication administration error where a medication labeled 'Do not crush' was crushed and mixed with apple sauce.
Failure to ensure appropriate care and monitoring for residents with urinary and bowel incontinence, including improper catheter care and placement.
Failure to maintain acceptable nutritional status for residents, including failure to monitor weight changes and notify responsible parties.
Food safety violations including expired and spoiled food items, improper storage and handling of food, and failure to discard contaminated food.
Failure to provide adequate facility assessment and staff training related to obtaining resident weights.
Infection prevention and control deficiencies including improper handling of soiled linens, failure to maintain isolation precautions, and inadequate staff education.
Failure to ensure resident call lights were accessible and within reach, and failure to provide education to staff regarding call light use.
Failure to provide adequate Quality Assurance and Performance Improvement (QAPI) program training and documentation.
Report Facts
Medication administration instances: 53
Weight loss percentage: 21.64
Weight loss percentage: 6.32
Weight loss percentage: 5.61
Resident weights reviewed: 7
Residents reviewed for skin integrity observations: 8
Residents reviewed for nutritional status: 4
Residents reviewed for catheter care: 5
Residents reviewed for call light accessibility: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Medication Technician | Observed crushing medication labeled 'Do not crush' and administering it to a resident. |
| Staff B | Licensed Practical Nurse (LPN) | Acknowledged skin integrity observation documentation was not completed as ordered. |
| Staff D | Nursing Assistant | Acknowledged catheter drainage bag was placed directly on the floor and not in a privacy bag. |
| Staff S | Nursing Assistant | Observed exiting a resident's room holding a soiled sheet and acknowledged usual practice. |
| Staff Q | Registered Nurse | Observed call light out of resident's reach and acknowledged resident would not be able to access it. |
| Staff T | Unit Assistant | Indicated making beds for residents and was unaware of any precautions in place. |
| Staff G | Dietitian | Unaware of resident weight loss and lack of nutrition plan for resident. |
| Staff H | Licensed Practical Nurse | Monitors all resident weights and runs monthly weight report. |
| Administrator | Unaware that newly hired Nursing Assistants did not receive training on obtaining resident weights. | |
| Director of Nursing Services | Unaware that newly hired Nursing Assistants did not receive training on obtaining resident weights. | |
| Director of Nursing Services | Interviewed regarding skin integrity observation documentation and infection control. | |
| Infection Control Nurse | Interviewed regarding infection control practices and observations. |
Inspection Report
Routine
Deficiencies: 8
Date: Feb 10, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, medication administration, dietary services, respiratory care, and food safety at Sunny View Nursing Home.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate pressure ulcer care, inadequate nutritional monitoring and intervention, improper respiratory care and oxygen administration, inappropriate medication administration, failure to follow dietary guidelines and menu planning, improper food preparation and serving, and non-compliance with food safety standards in the kitchen.
Deficiencies (8)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for 3 of 6 residents reviewed.
Failure to ensure residents maintain acceptable nutritional status and follow policy relative to weight and weight change for 2 of 9 residents reviewed.
Failure to provide safe and appropriate respiratory care for 3 of 5 residents reviewed for oxygen therapy.
Failure to ensure a resident's drug regimen is free from unnecessary drugs for 1 of 2 residents reviewed for pain medication.
Failure to ensure a resident's drug regimen is free from unnecessary psychotropic medication orders extending beyond 14 days without rationale for 1 of 4 residents reviewed.
Failure to provide a dietary menu that meets nutritional needs of residents and was reviewed by a qualified nutritional professional.
Failure to ensure residents receive food prepared in a form designed to meet individual needs for 5 of 5 residents observed.
Failure to ensure food is stored, served, and distributed in accordance with professional food service safety standards in the main kitchen.
Report Facts
Weight loss: 21.8
Pain level: 7
Oxygen flow rate: 2
Oxygen tubing change frequency: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Acknowledged failure to offload residents' heels as ordered. |
| Staff B | Registered Nurse (RN) | Acknowledged residents should have heels offloaded and oxygen administered as ordered. |
| Director of Nursing Services (DNS) | Director of Nursing Services | Expected residents' heels to be offloaded and oxygen to be administered as ordered; unable to provide rationale for extended psychotropic medication. |
| Staff C | Registered Nurse | Acknowledged admission weight was not obtained per facility policy. |
| Staff D | Registered Nurse | Acknowledged oxygen tubing was not labeled or dated and should be changed every three days. |
| Food Service Director | Food Service Director | Acknowledged dietary staff not wearing hair restraints and improper sanitization of kitchen equipment. |
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