Inspection Reports for Brush Country Nursing and Rehabilitation
6500 Brush Country Rd, Austin, TX 78749, TX, 78749
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
15.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
349% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Nov 11, 2025
Visit Reason
The inspection was conducted to assess compliance with pharmaceutical services and medication storage regulations at Brush Country Nursing and Rehabilitation.
Findings
The facility failed to provide timely pharmaceutical services for two residents, resulting in missed doses of pain medication, and failed to ensure proper storage and security of medications, including an unlocked medication cart and a medication refrigerator at an incorrect temperature.
Deficiencies (2)
Failed to provide pharmaceutical services to meet the needs of each resident, including timely ordering of medications for two residents.
Failed to ensure drugs and biologicals were labeled and stored properly, including locked compartments for controlled drugs.
Report Facts
Residents reviewed for pharmacy services: 9
Missed doses: 18
Medication refrigerator temperature: 52
Acceptable medication refrigerator temperature range: 36
Acceptable medication refrigerator temperature range: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Interviewed regarding medication ordering and storage practices. | |
| NP | Nurse Practitioner | Interviewed about medication orders and resident medication refusals. |
| ADM | Administrator | Interviewed about medication ordering policies and monitoring responsibilities. |
| ADON | Assistant Director of Nursing | Interviewed about medication storage policies and temperature monitoring. |
| DON | Director of Nursing | Interviewed about medication storage policies and monitoring. |
| MA B | Medication Aide | Interviewed about medication cart locking policies and practices. |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Oct 4, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident privacy and pain management following complaints and observations of deficiencies.
Findings
The facility failed to provide privacy curtains in a shared room for two residents, placing them at risk for decreased privacy and dignity. Additionally, the facility failed to provide effective pain management for a resident, resulting in an immediate jeopardy situation due to lack of timely administration of prescribed pain medication.
Deficiencies (2)
Failed to ensure privacy curtains were provided in the shared room of Residents #2 and #3, compromising privacy and dignity.
Failed to provide safe, appropriate pain management for Resident #1, resulting in immediate jeopardy to resident health or safety.
Report Facts
Residents observed for privacy: 7
Residents affected by privacy deficiency: 2
Residents reviewed for pain: 3
Residents affected by pain management deficiency: 1
Oxycodone 5mg pills admitted with Resident #1: 5
Oxycodone 5mg pills administered to Resident #1: 5
Oxycodone 5mg pills delivered on 10/02/2025: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Nurse who provided care to Resident #1 and Resident #2/#3, involved in pain medication ordering and privacy curtain observations |
| CNA B | Certified Nursing Assistant | Provided care for Residents #2 and #3, reported lack of privacy curtains |
| CNA C | Certified Nursing Assistant | Provided care for Residents #2 and #3, attempted to provide privacy using sheets |
| Assistant Maintenance Director | Responsible for hanging privacy curtains after deficiency was identified | |
| Administrator | Provided in-service training and oversight related to medication ordering and privacy issues | |
| DON | Director of Nursing | Involved in oversight of pain management and privacy curtain issues, conducted in-service training |
| ADON | Assistant Director of Nursing | Participated in audits, in-service training, and monitoring of medication ordering process |
| MD | Medical Doctor | Physician involved in Resident #1's pain medication orders and follow-up |
| NP | Nurse Practitioner | Involved in prescribing and authorizing pain medication for Resident #1 |
| RN D | Registered Nurse | In-serviced on medication ordering and pain management procedures |
| LVN E | Licensed Vocational Nurse | In-serviced on medication ordering and pain management procedures |
| MA F | Medication Aide | In-serviced on procedures for missing pain medications |
| MA G | Medication Aide | In-serviced on procedures for missing pain medications |
| LVN H | Licensed Vocational Nurse | In-serviced on medication ordering and pain management procedures |
| RN I | Registered Nurse | In-serviced on medication ordering and pain management procedures |
Inspection Report
Routine
Deficiencies: 15
Date: Aug 21, 2025
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident rights, medical record confidentiality, accurate assessments, PASARR screening, baseline and comprehensive care plans, activities of daily living, staffing sufficiency, medication storage, food service safety, infection prevention and control, equipment safety, and staff training.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to dignity and privacy, confidentiality of medical records, accurate and complete assessments, proper PASARR screening, timely and comprehensive care plans, provision of scheduled showers, adequate activities, sufficient nursing staff, secure medication storage and proper refrigeration, palatable and safe food service, infection control practices, maintenance of essential equipment, and staff training on care plans and PASARR.
Deficiencies (15)
Failed to ensure residents were treated with respect and dignity, including knocking on doors before entering rooms for 3 of 15 residents.
Failed to keep resident medical records private and confidential; medication cart left unlocked exposing resident information.
Failed to ensure accurate assessments reflecting residents' smoking status for 3 residents.
Failed to ensure PASARR screening was completed for a resident with mental illness prior to admission.
Failed to complete baseline care plan within 48 hours of admission for a resident.
Failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for 8 residents, including failure to update code status, activity plans, smoking status, and contact isolation.
Failed to provide scheduled showers 3 times a week for a resident, with multiple undocumented refusals and inconsistent shower provision.
Failed to provide ongoing activities program to meet residents' preferences and needs, including failure to provide in-room activities for 3 residents.
Failed to provide sufficient nursing staff to meet the needs of residents, resulting in delayed call light response and unmet care needs for 4 residents.
Failed to ensure medication carts were locked and medications secured; failed to maintain medication refrigerator temperature within required range.
Failed to serve palatable, attractive food at safe and appetizing temperatures; observed mushy vegetables, small portions, and open meal cart doors during delivery.
Failed to store, prepare, and serve food in accordance with professional standards including unlabeled and undated food items, improper refrigeration and freezer temperatures, water leaks contaminating food storage, and expired food items.
Failed to establish and maintain an infection prevention and control program including improper glove doffing and disposal, failure to wear PPE during high contact care, and failure to care plan for contact isolation.
Failed to maintain essential kitchen equipment in safe operating condition including walk-in freezer temperature out of range and refrigerator cooling fans leaking water.
Failed to develop, implement, and maintain an effective training program for new and existing staff, including lack of training for Social Worker and Marketing staff on PASRR and care plans.
Report Facts
Residents reviewed for resident rights: 15
Residents reviewed for medical record confidentiality: 5
Residents reviewed for accuracy of assessments: 3
Residents reviewed for PASARR services: 12
Residents reviewed for baseline care plans: 3
Residents reviewed for comprehensive care plans: 16
Residents reviewed for activities of daily living: 12
Residents reviewed for activities: 6
Residents reviewed for sufficient staffing: 20
Residents reviewed for medication storage: 3
Residents reviewed for food service safety: 1
Residents reviewed for infection control: 6
Residents reviewed for equipment safety: 1
Staff reviewed for training: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Named in deficiency for not knocking on resident doors before entering | |
| LVN B | Named in deficiency for not knocking on resident doors before entering | |
| RN D | Named in deficiency for leaving medication cart unlocked and not following HIPAA protocol | |
| CNA C | Named in deficiency for improper glove doffing and PPE disposal | |
| LVN E | Named in deficiency for not wearing PPE during gastrostomy tube medication administration | |
| CNA F | Named in deficiency for not wearing PPE during resident transfer and for nourishment refrigerator issues | |
| CNA G | Named in deficiency for not wearing PPE during resident transfer | |
| TN | Treatment Nurse | Named in deficiency for monitoring shower sheets and infection preventionist |
| MDSN | MDS Nurse | Named in deficiency for care plan and PASRR responsibilities |
| ADM | Administrator | Named in deficiency for oversight of PASRR, care plans, medication cart locking, and refrigeration issues |
| DON | Director of Nursing | Named in deficiency for oversight of resident rights, care plans, infection control, and medication storage |
| CDM | Certified Dietary Manager | Named in deficiency for food service and refrigeration issues |
| MAIN | Maintenance | Named in deficiency for refrigeration repairs and maintenance |
| Marketing | Named in deficiency for lack of PASRR training | |
| SW | Social Worker | Named in deficiency for lack of training on PASRR and care plans |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Aug 5, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to the development and implementation of comprehensive person-centered care plans within the required timeframes for residents.
Findings
The facility failed to develop and implement comprehensive care plans within 7 days of the comprehensive assessment and no more than 21 days after admission for 2 of 5 residents reviewed. Specifically, Resident #1's care plan was not updated to reflect removal of a foley catheter, and Resident #2 had no comprehensive care plan created, placing residents at risk of not receiving appropriate care.
Deficiencies (1)
Failed to develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Report Facts
Residents reviewed for care plan revision and timing: 5
Residents affected: 2
Days to develop care plan: 7
Days to develop care plan after admission: 21
Target date for catheter removal: Nov 25, 2025
BIMS score: 11
Baseline care plan date: May 24, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Stated that cares are generated by an RN and include any devices a resident had and had information to care for the resident. | |
| DON | Discussed responsibilities and expectations regarding comprehensive care plans and their updates. | |
| LVN B | Described components of a care plan including general needs, behaviors, ADL needs, and bowel and bladder information. | |
| MDS coordinator | Responsible for starting and updating comprehensive care plans; stated care plans are working documents updated as needed. | |
| ADM | Explained the purpose and expectations for comprehensive care plans and noted audits were being completed. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 2, 2025
Visit Reason
The inspection was conducted due to concerns that the facility failed to provide pharmaceutical services to meet the needs of residents, specifically that seven residents did not receive their scheduled 5:00 pm medications on multiple occasions.
Complaint Details
The complaint investigation found that seven residents did not receive their scheduled 5:00 pm medications on multiple dates, confirmed by resident interviews, family member statements, and MAR reviews. The facility was found to have no effective monitoring system to ensure timely medication administration. The Director of Nursing identified responsible staff and took corrective action including termination.
Findings
The facility failed to ensure that seven of ten residents reviewed received their medications as scheduled at 5:00 pm on various dates. Multiple medication omissions were documented in the Medication Administration Records (MAR) and confirmed by resident and family interviews. The Director of Nursing acknowledged issues and identified staff responsible, including termination of a medication aide. The facility policy requires medications to be administered within one hour of the prescribed time.
Deficiencies (1)
Failure to provide pharmaceutical services to meet the needs of each resident, including omission of scheduled 5:00 pm medications for seven residents.
Report Facts
Residents reviewed for pharmaceutical services: 10
Residents affected by medication omission: 7
Dates of missed medication administration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MA A | Medication Aide | Interviewed regarding medication administration practices and shift schedule |
| MA B | Medication Aide | Interviewed regarding medication administration practices and shift schedule |
| NP | Nurse Practitioner | Interviewed regarding communication about missed medication doses and protocol |
| DON | Director of Nursing | Interviewed regarding identification of staff responsible for medication omissions and corrective actions |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 7, 2025
Visit Reason
The inspection was conducted due to concerns about the facility's failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, specifically for Resident #1 who had worsening pressure wounds.
Complaint Details
The complaint investigation revealed that Resident #1 did not receive required wound care treatments on multiple occasions in April and May 2025, including missed treatments to sacral and left heel wounds. Weekly skin assessments were not conducted as required. Interviews with staff confirmed lapses in care and documentation. Immediate Jeopardy was identified on 05/06/25 and removed on 05/07/25 after corrective actions were implemented.
Findings
The facility failed to complete weekly skin assessments and provide consistent wound care for Resident #1, resulting in an Immediate Jeopardy (IJ) situation that was later removed. The resident's sacral and left heel wounds worsened due to missed treatments and assessments. The facility implemented a Plan of Removal including staff in-services, audits, and updated care plans.
Deficiencies (2)
Failure to complete weekly skin assessments or provide treatments to a pressure area on Resident #1's left foot, which developed into a pressure wound.
Failure to provide consistent wound care to Resident #1's sacral wound causing it to worsen.
Report Facts
Missed sacral wound treatments: 3
Missed left heel wound treatments: 6
Skin audit residents: 78
Surface area of sacral wound: 39
Braden Scale score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner (NP) | Interviewed regarding expectations for weekly skin assessments | |
| Wound Care Doctor (WCD) | Interviewed about wound assessments and treatments | |
| Director of Nursing (DON) | Interviewed about skin assessment expectations and conducted wound care assessments | |
| LVN A | Licensed Vocational Nurse | Interviewed about wound care rounds and treatment documentation errors |
| Social Worker (SW) | Conducted Emotional Distress Assessment for Resident #1 | |
| Administrator (ADM) | Involved in staff in-service and notified of Immediate Jeopardy | |
| Vice President of Clinical Services (VP of Clinical Services) | Trained DON and involved in QAPI meeting | |
| Corporate MDS Nurse | Updated Resident #1's care plan |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jan 8, 2025
Visit Reason
The inspection was conducted due to complaints regarding medication errors at discharge and concerns about nursing coverage and medication administration timeliness.
Complaint Details
The complaint investigation focused on medication errors at discharge, including Resident #1 receiving the wrong medication blister pack, and concerns about nursing coverage and medication administration timeliness. The medication error was discovered before administration and no adverse outcomes were reported. Interviews with family members, nursing staff, and administration confirmed the issues.
Findings
The facility failed to ensure correct medications were provided to a resident at discharge, failed to have a registered nurse on duty for the required hours, and failed to administer medications in a timely manner for multiple residents, potentially placing residents at risk of harm.
Deficiencies (3)
Failed to ensure Resident #1 had the correct medications prescribed upon discharge, resulting in a medication error with potential adverse effects.
Failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 8 of 9 days reviewed, and failed to ensure an RN charge nurse was on duty for required days.
Failed to provide pharmaceutical services including timely administration of all drugs and biologicals to meet the needs of residents #1 and #2, with multiple late and missed doses documented.
Report Facts
Residents reviewed for discharge rights: 3
Residents affected by medication error: 1
Days without RN charge nurse coverage: 8
Days reviewed for RN coverage: 9
Residents reviewed for pharmaceutical services: 5
Residents affected by pharmaceutical service deficiencies: 2
Missed doses Resident #1: 5
Missed doses Resident #2: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NP | Interviewed regarding medication error and potential negative impacts. | |
| DON (Director of Nursing) | Interviewed regarding expectations for medication administration and RN coverage. | |
| ADM (Administrator) | Interviewed regarding expectations for medication administration and discharge procedures. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 18, 2024
Visit Reason
The inspection was conducted due to complaints regarding inaccurate documentation of medical records for three residents, including failure to document facility self-reported incidents and vital signs accurately.
Complaint Details
The complaint investigation revealed that Residents #1 and #2 had facility self-reported incidents that were not documented in their electronic medical records, and Resident #3's vital signs were not accurately documented. The Corporate RN stated that the injury incident for Resident #2 on 11/14/24 was not entered in progress notes, indicating a lack of documentation despite believed follow-up care.
Findings
The facility failed to ensure accurate documentation of medical records for three residents, including missing documentation of reported incidents for Residents #1 and #2, and incomplete vital signs documentation for Resident #3. These deficiencies could result in errors in care and treatment.
Deficiencies (1)
Failure to safeguard resident-identifiable information and maintain accurate medical records for Residents #1, #2, and #3.
Report Facts
BIMS score: 9
BIMS score: 8
BIMS score: 15
Incident date: Oct 18, 2024
Incident date: Nov 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker (SW) | Reported incident regarding Resident #1 on 10/18/24 | |
| Administrator (ADM) | Expected nurses to document incidents and changes; interviewed on 11/18/24 | |
| Licensed Vocational Nurse (LVN) TN | Confirmed missing vital signs documentation for Resident #3 on 10/30/24 and 10/31/24 | |
| Corporate Registered Nurse (RN) | Commented on missing documentation for Resident #2's injury incident on 11/14/24 |
Inspection Report
Routine
Deficiencies: 4
Date: Jul 23, 2024
Visit Reason
The inspection was conducted to assess compliance with resident rights, respiratory care, therapeutic diet provision, and food safety standards at Brush Country Nursing and Rehabilitation.
Findings
The facility was found deficient in ensuring resident privacy by failing to knock before entering rooms, safe handling and maintenance of oxygen equipment, provision of physician-prescribed therapeutic diets, and proper food storage and thawing practices in the kitchen.
Deficiencies (4)
Facility failed to ensure resident rights for personal privacy by not knocking on doors before entering rooms for 5 residents.
Facility failed to ensure safe handling, humidification, cleaning, storage, and dispensing of oxygen for 3 residents, including failure to date oxygen tubing and maintain humidifier water.
Facility failed to provide the physician prescribed mechanical soft diet to 1 resident, resulting in the resident receiving a regular diet.
Facility failed to store, prepare, distribute, and serve food in accordance with professional standards, including failure to label and date food items and improper thawing of meat.
Report Facts
Residents affected: 5
Residents affected: 3
Residents affected: 1
Residents affected: 1
Temperature: 63
Temperature: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA B | Named in privacy deficiency for not knocking on doors | |
| DON | Director of Nursing | Provided statements regarding resident rights and oxygen tubing policy |
| ADM | Administrator | Provided statements regarding resident rights and meal tray checking |
| ICP | Infection Control Practitioner | Provided statements regarding oxygen tubing and humidifier bottle policy |
| LVN A | Licensed Vocational Nurse | Provided statements regarding oxygen tubing and humidifier bottle policy |
| LVN B | Licensed Vocational Nurse | Provided statements regarding meal tray checking |
| CK A | Cook | Observed and interviewed regarding food temperature and safety |
| CK B | Cook | Provided statements regarding food labeling and thawing |
| DM | Dietary Manager | Provided statements regarding food labeling, thawing, and safety |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 15, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to ensure proper discharge procedures and timely notification before transfer or discharge for Resident #1.
Complaint Details
The complaint investigation focused on Resident #1's discharge process, including failure to document discharge planning and failure to provide timely 30-day discharge notice. The facility was found noncompliant in both areas, with interviews confirming the issues and the discharge occurring earlier than the notice date.
Findings
The facility failed to complete and document discharge planning and summary for Resident #1 upon discharge on 4/12/2024, and failed to provide the required 30-day notice before discharge. Interviews and record reviews revealed lack of proper discharge documentation and communication, placing residents at risk of improper discharges.
Deficiencies (2)
Failed to complete and document discharge planning and summary upon discharge for Resident #1.
Failed to provide timely notification (at least 30 days) before transfer or discharge for Resident #1.
Report Facts
Residents reviewed for discharge requirements: 8
Residents reviewed for discharge notices: 8
BIMS score: 12
Discharge date: Apr 12, 2024
Notice date: Mar 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Took care of Resident #1 on the day of discharge and did not complete discharge note |
| Nurse Practitioner | Authored discharge order for Resident #1 on 4/12/2024 and stated not involved in discharge planning | |
| SW | Social Worker | Responsible for discharge planning but had no notes on discharge planning for Resident #1 and was not present at discharge |
| ADON | Assistant Director of Nursing | Transported Resident #1 to new facility and commented on discharge planning process |
| MDS Coordinator | Stated SW did all discharge planning and was not involved with Resident #1's discharge | |
| Administrator | Involved in Resident #1's discharge and commented on discharge notices and family involvement | |
| DON | Director of Nursing | Stated discharge planning review was to be opened on admission and closed on discharge; noted discharge summary was not completed |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 5, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide Resident #1 and her representative with a copy of the care plan meeting results conducted on 01/25/24, despite multiple requests.
Complaint Details
The complaint was substantiated as the facility did not provide the requested care plan meeting results despite multiple requests from Resident #1's family member, who was identified as the responsible party. Interviews with Resident #1, her family member, the Director of Nursing (DON), and the Social Worker (SW) confirmed the failure to provide the documentation.
Findings
The facility failed to provide a copy of the care plan meeting results to Resident #1 and her representative after requests on 02/04/24 and 02/16/24. This failure could place the resident at risk for not being involved in care decisions, potentially decreasing quality of care and psychosocial well-being.
Deficiencies (1)
Failure to provide a copy of the care plan meeting results to Resident #1 and her representative upon request.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | DON | Interviewed regarding the failure to provide care plan meeting results and responsibility for communication. |
| Social Worker | SW | Responsible for communicating and addressing requests for care plan meeting results; explained reasons for not providing the documentation. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 26, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide appropriate urinary catheter care and prevent urinary tract infections for Resident #1, which resulted in the resident being sent to the hospital ICU for sepsis.
Complaint Details
The complaint investigation found substantiated failures in catheter care for Resident #1, including incorrect transcription of orders by RN A and improper catheter insertion by LVN B, resulting in Resident #1's hospitalization for sepsis.
Findings
The facility failed to correctly transcribe and follow physician orders for Resident #1's foley catheter care, leading to improper catheter insertion and subsequent complications including infection, obstruction, and sepsis requiring hospital admission. Interviews with staff and review of medical records confirmed these failures and the risk posed to residents with indwelling catheters.
Deficiencies (1)
Failure to provide appropriate care for residents with urinary catheters, including incorrect transcription of catheter orders and improper catheter insertion.
Report Facts
Residents affected: 1
Foley catheter flush volume: 60
Antibiotic dosage: 100
Foley catheter size: 16
Date of catheter change order: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Failed to correctly transcribe Resident #1's foley catheter order and worked on day of urologist appointment and catheter care |
| LVN B | Licensed Vocational Nurse | Did not insert Resident #1's foley catheter according to physician orders and was nurse on duty when Resident #1 was sent to hospital ER |
| Wound care nurse | Informed LVN B about catheter change order and noted order should have indicated use of coude catheter | |
| DON | Director of Nursing | Discussed Resident #1's catheter issues and expectations for staff to follow physician orders |
Inspection Report
Routine
Deficiencies: 1
Date: Sep 28, 2023
Visit Reason
The inspection was conducted due to a failure by the facility to maintain comfortable and safe temperature levels (71 to 81 degrees Fahrenheit) in resident rooms, specifically for Resident #1 and Resident #2, whose rooms reached temperatures as high as 88.9 degrees Fahrenheit.
Findings
The facility failed to maintain ambient room temperatures within the safe range, exposing residents to potential risks of heat exhaustion, dehydration, hospitalization, and death. Multiple staff interviews and observations confirmed the air conditioning compressor was broken for about a week, portable AC units were not functioning properly, and staff did not adequately monitor or address the high temperatures. Residents were not moved despite offers, and monitoring of room temperatures was inconsistent and inadequately documented.
Deficiencies (1)
Failure to maintain resident rooms at comfortable and safe temperature levels between 71 and 81 degrees Fahrenheit, with rooms reaching up to 88.9 degrees Fahrenheit.
Report Facts
Temperature reading: 88.9
Temperature reading: 88.8
Temperature reading: 81.6
Date: Sep 19, 2023
Date: Sep 25, 2023
Temperature range: 71
Temperature range: 81
Temperature readings: Array
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Observed and interviewed regarding room temperature and portable AC unit in Resident #1's room |
| Maintenance Manager | Responsible for monitoring room temperatures and maintenance of AC units; interviewed multiple times regarding compressor outage and temperature checks | |
| CNA D | Certified Nursing Assistant | Interviewed about observations of room temperatures and reporting practices |
| Administrator | Interviewed regarding AC compressor issues, resident room temperatures, and facility policies | |
| MA G | Medication Aide | Interviewed about observations of room temperature and communication with residents and staff |
| CNA E | Certified Nursing Assistant | Interviewed about observations of heat on 300 hall and reporting |
| CNA F | Certified Nursing Assistant | Interviewed about working in affected rooms and observations of temperature |
| LVN C | Licensed Vocational Nurse | Interviewed about overnight shifts and observations of room temperature |
| DON | Director of Nursing | Interviewed regarding clinical monitoring of residents and facility temperature policies |
| Maintenance Assistant | Interviewed about compressor outage and temperature checks |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 15, 2023
Visit Reason
The inspection was conducted based on complaints regarding the cleanliness of resident rooms and failure to provide necessary personal hygiene care to dependent residents.
Complaint Details
Complaints included concerns about poor cleanliness of resident rooms and failure to provide scheduled bathing to Resident #234. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to ensure resident rooms were cleaned and sanitized daily, placing residents at risk of disease spread. Additionally, the facility failed to provide scheduled baths or showers to a dependent resident, risking dignity issues and skin breakdown.
Deficiencies (2)
Failed to ensure resident rooms were cleaned and sanitized daily according to the facility's Housekeeping Workers' Checklist.
Failed to ensure a dependent resident received scheduled baths or showers since admission.
Report Facts
Residents affected: 3
Residents affected: 1
Scheduled baths/showers per week: 3
Dates missed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN P | Day Charge Nurse | Ensured residents received baths/showers; unaware of Resident #234's missed showers |
| CNA W | Certified Nursing Assistant | Responsible for providing scheduled baths/showers; confirmed Resident #234 missed showers |
| Housekeeping Aide H | Housekeeping Aide | Cleaned resident rooms; stated she was the only housekeeper available during inspection |
| Administrator | Facility Administrator | Terminated Housekeeping Supervisor; responsible for housekeeping oversight |
| DON | Director of Nursing | Interviewed about cleanliness concerns and bathing protocol; planned in-service for staff |
| ADON | Assistant Director of Nursing | Discussed housekeeping staffing and bathing protocols |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Jun 15, 2023
Visit Reason
The inspection was conducted as part of the facility's annual survey to assess compliance with regulatory requirements related to resident care, environment, medication management, food service, infection control, and other operational standards.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe, clean, and homelike environment; inadequate assistance with activities of daily living such as bathing; unsecured medication carts; poor food quality and improper food storage practices; and failure to implement effective infection prevention and control measures, including sanitization of shared equipment.
Deficiencies (6)
Failed to ensure resident rooms were cleaned and sanitized daily, leading to dirty floors and bathrooms in multiple rooms.
Failed to provide necessary bathing and hygiene services to a dependent resident, resulting in missed showers since admission.
Medication carts #1 and #2 were left unlocked and accessible to unauthorized personnel, risking medication diversion and resident harm.
Food served was not palatable or properly prepared; juices were watered down or unavailable, and puree meals lacked flavor.
Failed to properly label and date food items and maintain sanitary conditions in the kitchen, including uncovered food and expired spices.
Failed to sanitize blood pressure equipment between resident use, risking cross-contamination and infection.
Report Facts
Residents affected: 3
Residents affected: 8
Residents affected: 1
Residents affected: 1
Medication carts reviewed: 4
Dietary diets: 68
Dietary diets: 7
Dietary diets: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MA S | Medical Assistant | Failed to sanitize blood pressure cuff and device between resident uses |
| RN-R | Registered Nurse | Responsible for medication cart #1, left it unlocked |
| LVN P | Licensed Vocational Nurse | Day Charge nurse for 300 and 400 Halls, responsible for ensuring residents received scheduled baths/showers |
| CNA W | Certified Nursing Assistant | Responsible for providing scheduled showers/baths to residents |
| DM | Dietary Manager | Managed food preparation and kitchen sanitation, acknowledged issues with juice machines and food palatability |
| ADON | Assistant Director of Nursing | Provided statements on housekeeping and medication cart protocols |
| DON | Director of Nursing | Oversaw nursing and infection control policies, acknowledged housekeeping and medication cart deficiencies |
| Administrator | Facility Administrator | Responsible for overall facility operations, including housekeeping and infection control compliance |
Inspection Report
Routine
Deficiencies: 2
Date: Apr 18, 2023
Visit Reason
The inspection was conducted to assess compliance with federal and state regulations regarding resident rights, dignity, and nutritional care at Brush Country Nursing and Rehabilitation.
Findings
The facility failed to treat residents with dignity by serving meals on disposable plasticware and Styrofoam plates instead of dishes and silverware, affecting three residents. Additionally, the facility failed to provide milk with dry cereal and house shakes as ordered for three residents, risking inadequate nutrition.
Deficiencies (2)
Failure to use dishes and silverware for residents, instead using disposable plasticware and Styrofoam, leading to an undignified environment.
Failure to provide milk with dry cereal and house shakes as ordered for residents, risking inadequate nutrition.
Report Facts
Meal trays served with Styrofoam/plasticware: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DM | Dietary Manager who explained the use of Styrofoam/plasticware and meal tray accuracy | |
| DON | Director of Nursing who commented on the use of Styrofoam/plasticware and meal tray checks | |
| AD | Administrator who was unable to locate resident council minutes and was unsure about Styrofoam use | |
| ADON | Assistant Director of Nursing who stated nurses check meal trays for accuracy |
Inspection Report
Deficiencies: 1
Date: Feb 11, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with providing necessary care and assistance for activities of daily living, specifically ensuring residents unable to perform these activities received proper personal hygiene care.
Findings
The facility failed to provide showers to three residents (Resident #1, Resident #2, and Resident #3) in accordance with their shower schedules, placing them at risk of hygiene decline, skin breakdown, and reduced self-worth. Observations and interviews confirmed residents went extended periods without showers, and staff acknowledged challenges with scheduling and notification.
Deficiencies (1)
Failure to provide showers to residents in compliance with their shower schedules, resulting in risk of hygiene decline and skin issues.
Report Facts
Residents reviewed for ADLs: 5
Residents affected: 3
Days without shower: 8
Showers received in last 30 days: 2
BIMS scores: 15
BIMS scores: 11
BIMS scores: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON | Director of Nursing | Stated expectations for shower frequency and responsibility for care tracker oversight |
| RN A | Registered Nurse | Described shower schedule process and notification expectations |
| CNA B | Certified Nursing Assistant | Reported knowledge of shower scheduling via kiosk and challenges due to short staffing |
| ADM | Administrator | Outlined nurses' responsibility for ensuring showers and expectations for notification of refusals |
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