Deficiencies (last 3 years)
Deficiencies (over 3 years)
34.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
921% worse than Rhode Island average
Rhode Island average: 3.4 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
92% occupied
Based on a July 2025 inspection.
Occupancy rate over time
Inspection Report
Deficiencies: 1
Date: Nov 19, 2025
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of practice regarding respiratory care for residents, specifically focusing on the administration of BiPAP therapy to a resident following hospital discharge.
Findings
The facility failed to ensure that a resident received necessary BiPAP respiratory care as ordered for three days after readmission, resulting in potential harm due to delayed treatment. Interviews and record reviews confirmed the BiPAP machine was not administered as prescribed until four days after hospital discharge.
Deficiencies (1)
F 0695: The facility failed to provide safe and appropriate respiratory care by not administering BiPAP therapy as ordered to a resident for three days after readmission. This delay contributed to worsening respiratory condition and potential harm.
Report Facts
Days BiPAP not administered: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Nurse Practitioner | Authored progress note indicating resident's worsening condition due to lack of BiPAP |
| Staff B | Nurse Practitioner | Authored progress note and interviewed by surveyor regarding BiPAP delay |
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: 7
Date: Jul 25, 2025
Visit Reason
The inspection was conducted following a complaint and a facility-reported incident regarding failure to immediately notify the resident's physician of a change in condition, resulting in hospitalization, and concerns about quality of care and compliance with physician orders.
Complaint Details
The complaint investigation was triggered by a community reported complaint alleging that a resident arrived at the hospital after a suspected unwitnessed fall with severe injuries. The investigation found failures in timely physician notification, adherence to physician orders, and appropriate care leading to hospitalization.
Findings
The facility failed to timely notify the physician of a resident's change in condition leading to hospitalization, failed to follow physician orders for oxygen and orthostatic blood pressure monitoring, failed to manage significant weight discrepancies, and failed to provide appropriate bowel care. Additionally, there were deficiencies in staff competency, medication administration, documentation, food service safety, and environmental sanitation.
Deficiencies (7)
F580: The facility failed to immediately notify the resident's physician of a change in condition, resulting in delayed hospital transfer for one resident.
F658: The facility failed to ensure services met professional standards related to oxygen use, orthostatic blood pressure monitoring, and weight discrepancy management for multiple residents.
F684: The facility failed to provide treatment and care according to orders, including failure to obtain orthostatic vital signs and notify physician of condition changes for one resident.
F690: The facility failed to provide appropriate care for constipation and failed to notify the physician when a resident went without a bowel movement for five days.
F726: The facility failed to ensure nurses and aides had appropriate competencies, including failure to identify condition changes, administer oxygen as ordered, document accurately, and administer medications properly for one resident.
F812: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, including unsanitary kitchen conditions, unlabeled food items, improper food storage temperatures, and uncovered silverware on meal trays.
F921: The facility failed to maintain a sanitary and comfortable environment, with food trays left uncovered in hallways after meal hours containing partially consumed food.
Report Facts
Residents reviewed: 4
Residents reviewed for weight discrepancies: 7
Weight discrepancy: 32.7
Oxygen saturation readings: 77
Dry storage room temperature: 85
Food product expiration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Named in findings related to failure to administer oxygen, inaccurate documentation, and medication administration errors |
| Staff B | Registered Nurse (RN) | Named in findings related to delayed physician notification |
| Staff C | Registered Nurse (RN) | Named in findings related to failure to notify on-call provider |
| Staff D | Medical Doctor | Resident's physician interviewed regarding expectations for notification |
| Staff E | Licensed Practical Nurse (LPN) | Named in interview regarding weight reweigh procedures |
| Staff F | Licensed Practical Nurse (LPN) | Named in interview regarding weight documentation |
| Staff G | Nurse Practitioner | Named in interview regarding expectations for bowel movement notification |
| Director of Nursing Services | Director of Nursing Services | Named in multiple interviews regarding facility failures and lack of evidence for compliance |
| Assistant Director of Nursing Services | Assistant Director of Nursing Services | Named in interview regarding lack of evidence for timely physician notification |
| Director of Food Service | Director of Food Service | Named in interview acknowledging food service deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 25, 2025
Visit Reason
The inspection was conducted following a complaint and a facility-reported incident regarding a resident who was hospitalized after a suspected unwitnessed fall resulting in serious injuries.
Complaint Details
The complaint investigation was substantiated. The resident was hospitalized with bruising, a grade 4 splenic laceration, and displaced rib fractures after suspected unwitnessed falls. The facility failed to monitor orthostatic vital signs as ordered.
Findings
The facility failed to provide necessary treatment and care according to professional standards by not obtaining orthostatic vital signs as ordered, failing to identify a change in the resident's condition, and not notifying the physician for one resident reviewed for hospitalization.
Deficiencies (1)
F 0684: The facility failed to obtain orthostatic vital signs as ordered, identify changes in the resident's condition, and notify the physician for Resident ID #8 who was hospitalized after falls resulting in fractured ribs and a lacerated spleen.
Report Facts
Deficiencies cited: 1
Dates of falls: 4
Orthostatic vital sign monitoring order dates: 3
Orthostatic vital sign monitoring order duration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director Nursing Services | Interviewed during survey; unable to provide evidence of orthostatic vital signs obtained |
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: Apr 18, 2025
Visit Reason
The inspection was conducted in response to community-reported complaints alleging failure to administer pain medications to Resident ID #1 and issues related to the use of an air mattress for the same resident.
Complaint Details
The complaint investigation was substantiated based on findings that Resident ID #1 did not receive PRN morphine as ordered despite complaints of pain, resulting in transfer to hospital. Additional concerns about the lack of physician orders for an air mattress were also confirmed.
Findings
The facility failed to implement comprehensive person-centered care plans for pain management for four residents, including Resident ID #1 who did not receive prescribed PRN morphine leading to hospitalization. Additionally, the facility failed to follow physician's orders for pain and anxiety medication administration and lacked physician orders for the use of an air mattress for Resident ID #1.
Deficiencies (2)
F 0656: The facility failed to implement a complete care plan for pain medication administration for 4 of 4 residents reviewed, including failure to document and monitor pain as outlined in care plans.
F 0658: The facility failed to meet professional standards by not following physician's orders for pain and anxiety medication administration for Resident ID #1 and lacked physician orders for the use of an air mattress.
Report Facts
Residents reviewed for pain medication administration: 4
Residents reviewed for air mattress use: 3
BIMS scores: 14
BIMS scores: 3
BIMS scores: 0
BIMS scores: 6
Morphine dosage: 15
Morphine concentrate dosage: 0.75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse, Staff B | Acknowledged failure to document residents' pain and only asking residents about pain | |
| Assistant Director of Nursing (ADNS) | Indicated expectation that staff follow care plans and acknowledged lack of physician orders for air mattress | |
| Licensed Practical Nurse (LPN), Staff A | Reported resident transfer to hospital due to inability to manage pain and administration of PRN morphine only once | |
| Nurse Practitioner | Unaware that PRN morphine was not administered before resident's hospital transfer | |
| Licensed Practical Nurse (LPN), Staff C | Authored nursing progress note requesting new air mattress due to intermittent beeping |
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
Complaint Investigation
Deficiencies: 2
Date: Oct 10, 2024
Visit Reason
The inspection was conducted following a community reported complaint alleging improper care related to resident transfers and failure to complete required weekly skin evaluations.
Complaint Details
The complaint alleged that a resident's calves were often injured from bad transfers. The investigation found failure to complete weekly skin assessments and lack of competency training for mechanical lifts.
Findings
The facility failed to meet professional standards of quality for physician's orders for 2 of 3 residents reviewed, specifically failing to complete and document weekly skin evaluations as ordered. Additionally, the facility failed to ensure nursing assistants had completed required competencies for safe use of mechanical lifts prior to providing care.
Deficiencies (2)
F 0658: The facility failed to complete and document weekly skin evaluations as ordered for Residents #1 and #2, despite signatures indicating completion.
F 0726: The facility failed to ensure nursing assistants Staff A and Staff B completed competencies for safe patient handling with mechanical lifts prior to providing care.
Report Facts
Residents reviewed for physician's orders: 3
Staff reviewed for competencies: 5
Dates weekly skin evaluations signed off: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | Interviewed and unable to provide evidence of completed weekly skin assessments. | |
| Regional Nurse | Interviewed and unable to provide evidence that mechanical lift competencies were completed for Staff A and B. |
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
Routine
Deficiencies: 10
Date: Jul 11, 2024
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory requirements related to resident care, medication administration, food safety, infection control, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to provide effective communication for non-English speaking residents, inadequate notification of discharges to the Ombudsman, insufficient dialysis care, lack of annual performance reviews for nursing assistants, medication administration errors, improper medication storage, failure to provide nourishing bedtime snacks, food safety violations including expired foods and inadequate dishwasher sanitation, lack of active certified food safety manager during all kitchen hours, ineffective QAPI program, and lapses in infection prevention and control practices.
Deficiencies (10)
F 0550: Facility failed to treat a Spanish-speaking resident with respect and dignity, resulting in communication barriers and unmet individual needs.
F 0623: Facility failed to provide timely written notification of transfer or discharge to the State Long-Term Care Ombudsman for two discharged residents.
F 0698: Facility failed to ensure dialysis care met professional standards for two residents, including lack of physician orders for AVF dressing and incomplete assessment of thrill and bruit.
F 0730: Facility failed to complete annual performance reviews for five nursing assistants within the last 12 months.
F 0760: Facility failed to ensure residents were free from significant medication errors for two residents, including missed insulin and phosphate binder doses without proper documentation or provider notification.
F 0761: Facility failed to store drugs and biologicals properly, including undated opened inhalers and insulin stored outside refrigeration.
F 0809: Facility failed to provide nourishing bedtime snacks to residents, resulting in more than 14 hours between evening meal and breakfast without snacks.
F 0812: Facility failed to prepare, store, and distribute food according to professional standards, including expired foods, unlabeled food items, improper packaging, inadequate dishwasher sanitation, lack of beard restraint on food service worker, and absence of active certified food safety manager during all kitchen hours.
F 0865: Facility failed to implement and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program.
F 0880: Facility failed to maintain infection prevention and control program, including improper use of PPE and hand hygiene by staff, failure to follow enhanced barrier precautions for residents with MDROs, and improper handling and storage of linens.
Report Facts
Residents affected: 5
Medication administration errors: 2
Medication carts observed: 4
Expired yogurt cups: 22
Dates dishwasher lint trap not emptied: 19
Dates without active Certified Food Safety Manager: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Nursing Assistant | Named in infection control finding for failure to wear gloves and perform hand hygiene |
| Staff C | Licensed Practical Nurse | Named in communication barrier finding with Spanish-speaking resident |
| Staff A | Social Worker | Named in communication and discharge notification findings |
| Staff F | Registered Nurse | Named in medication administration and food safety findings |
| Staff O | Registered Nurse | Named in infection control finding for improper wound care and cross-contamination |
| Staff N | Housekeeper | Named in infection control finding for failure to use PPE and hand hygiene in contact precaution room |
| Staff M | Dietary Cook | Named in food safety finding for expired food safety license |
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
Complaint Investigation
Deficiencies: 1
Date: Jun 6, 2024
Visit Reason
The inspection was conducted in response to a community reported complaint alleging that a resident did not receive medications as ordered on the second shift of 5/30/2024.
Complaint Details
The complaint alleged that the resident did not receive medications on the second shift of 5/30/2024 as ordered. The complaint was substantiated based on record reviews and staff interviews.
Findings
The facility failed to ensure that a resident received treatment and care in accordance with professional standards by not following a physician's order requiring second nurse verification of medication administration on specified dates in May and June 2024. Interviews with nursing staff and the Director of Nursing confirmed the lack of required second nurse verification.
Deficiencies (1)
F 0658: The facility failed to ensure a resident's medications were verified by a second nurse during administration on 5/30/2024, 6/3/2024, 6/4/2024, and 6/5/2024 as ordered.
Report Facts
Dates of missing second nurse verification: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Acknowledged not verifying medication administration with a second nurse on 6/3, 6/4, and 6/5/2024. |
| Staff B | Licensed Practical Nurse | Acknowledged not verifying medication administration with a second nurse on 5/30/2024. |
| Director of Nursing Services | Unable to provide evidence that the resident's medications were verified by a second nurse on the specified dates. |
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
Complaint Investigation
Deficiencies: 1
Date: Oct 16, 2023
Visit Reason
The inspection was conducted in response to a community-reported complaint received on 2023-10-13 regarding medication errors for Resident ID #1.
Complaint Details
The complaint was substantiated based on surveyor observation, record review, and staff interviews confirming medication storage violations and lack of resident assessment for self-administration.
Findings
The facility failed to store all drugs and biologicals in locked compartments for Resident ID #1, leaving medications unattended at the bedside. Staff acknowledged this was a common practice and the resident had not been assessed for competency to self-administer medications.
Deficiencies (1)
F 0761: The facility failed to store all drugs and biologicals in locked compartments for Resident ID #1, leaving medications unattended at the bedside. Staff interviews confirmed this practice and lack of resident competency assessment for self-administration.
Report Facts
Date of complaint received: Oct 13, 2023
Date of survey: Oct 16, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Acknowledged leaving medications unattended and signing off medication administration |
| Director of Nursing Services | Director of Nursing Services | Acknowledged common practice of leaving medications unattended and lack of resident competency assessment |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 5, 2023
Visit Reason
The inspection was conducted in response to a community complaint alleging that Resident ID #1 was given the wrong medications on several occasions, potentially endangering the resident's life.
Complaint Details
The complaint was submitted to the Rhode Island Department of Health on 10/4/2023 alleging that Resident ID #1 had been given the wrong medications on several occasions and felt his/her life had been put in danger. The complaint was substantiated by record reviews and staff interviews.
Findings
The facility failed to ensure services met professional standards of quality related to Nursing Assistants administering medications beyond their scope of practice. A Nursing Assistant administered medications to Resident ID #1 without proper licensure, contrary to facility policy and state regulations.
Deficiencies (1)
F 0658: The facility failed to ensure services met professional standards of quality related to Nursing Assistants scope of practice for medication administration. A Nursing Assistant administered medications to Resident ID #1 without being licensed to do so.
Report Facts
Date of complaint: Oct 4, 2023
Date of survey: Oct 5, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Documented medication administration and delegated medication administration to Nursing Assistant |
| Staff B | Nursing Assistant (NA) | Administered medications to resident without licensure |
| Director of Nursing Services | Confirmed Nursing Assistants should not administer medications and could not provide evidence of professional standards being met |
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
Routine
Deficiencies: 8
Date: May 22, 2023
Visit Reason
Routine inspection survey conducted to assess compliance with professional standards of quality, infection control, nutrition, safety, and other regulatory requirements at Brentwood Health Center.
Findings
The facility failed to meet professional standards in multiple areas including incomplete weekly skin integrity observations for several residents, improper medication administration, inadequate catheter care, failure to maintain residents' nutritional status, improper food storage, insufficient staff training, infection control lapses related to VRE precautions, and failure to maintain accessible call light systems for residents.
Deficiencies (8)
F0658: The facility failed to complete weekly skin integrity observations as ordered for 8 residents and administered medication outside manufacturer instructions for 1 resident.
F0690: The facility failed to ensure appropriate catheter care for 1 resident, including failure to keep the Foley catheter drainage bag off the floor.
F0692: The facility failed to maintain acceptable nutritional status for 4 residents, including failure to monitor weights, notify providers, and implement care plans for significant weight loss.
F0812: The facility failed to ensure food safety by storing expired and moldy bread in the main kitchen.
F0838: The facility failed to provide required training on obtaining resident weights to 7 newly hired nursing assistants as outlined in the facility assessment.
F0880: The facility failed to maintain an effective infection prevention and control program, including improper handling of soiled linen and failure to implement contact precautions for residents colonized with VRE.
F0919: The facility failed to ensure call light systems were accessible to 5 residents, with call lights observed out of reach during multiple observations.
F0944: The facility's Quality Assurance and Performance Improvement program lacked mandatory training and did not inform staff of program elements and goals.
Report Facts
Medication administrations: 53
Weight loss percentage: 18.87
Weight loss percentage: 21.34
Weight loss percentage: 7.81
Weight loss percentage: 6.32
Expired bread loaves: 16
Moldy bread loaves: 3
Nursing Assistants without weight training: 7
Residents with inaccessible call lights: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Medication Technician | Observed crushing medication against manufacturer instructions and administering it 53 times to Resident ID #62. |
| Staff B | Licensed Practical Nurse | Acknowledged incomplete skin integrity observations for multiple residents. |
| Director of Nursing Services | Director of Nursing Services | Interviewed multiple times acknowledging failures in documentation, training, and infection control. |
| Staff S | Nursing Assistant | Observed carrying soiled linen improperly on North Unit. |
| Staff D | Nursing Assistant | Observed placing clean personal laundry on dirty linen carts. |
| Staff U | Nursing Assistant in Training | Assisted resident with personal care without wearing protective gown despite VRE precautions. |
| Staff T | Unit Assistant | Made beds for VRE colonized residents without wearing gown or awareness of precautions. |
| Staff Q | Registered Nurse | Unaware of residents' VRE status and call light accessibility issues. |
| Staff F | Nurse Practitioner | Unaware of resident's severe weight loss until informed during survey. |
| Staff G | Dietitian | Unaware of resident's severe weight loss and unfamiliar with facility policy. |
| Staff H | Licensed Practical Nurse | Monitors resident weights but was not informed of significant weight loss events. |
| Administrator | Administrator | Unable to provide evidence of mandatory training for newly hired nursing assistants or QAPI training. |
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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