Brentwood Place Four

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 (Residents #1) of 4 reviewed for oxygen. The facility failed to ensure Residents #1 had a written orders for oxygen administration when Resident#1 was receiving oxygen therapy on 05/27/26. This failure placed residents who received oxygen therapy at risk for inadequate or inappropriate amounts of oxygen delivery and ineffective treatment. Record review of Resident #1's quarterly MDS assessment, dated 04/02/26, revealed Resident #1 was [AGE] years old male admitted to facility on 12/29/25 and readmitted [DATE]. Resident#1 active diagnosis included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 4 (Resident #16, Resident #62, Resident #194 and Resident#29) of 18 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #16 had her thumb nail cleaned and trimmed on 06/09/25. 2- Resident #62 had his fingernails cleaned and trimmed on 06/08/25. 3- Resident #194 had his fingernails cleaned and trimmed on 06/08/25. 4- Resident #29 had his fingernails cleaned and trimmed on 6/8/25. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 (100/200 hall) of 3 nurse medication carts reviewed for pharmacy services. The facility failed to ensure LVN O, LVN P, and LVN R responsible for the 100/200 hall nurse cart , counted controlled drugs every shift change. This failure could place residents at risk of not having the medication available due to possible drug diversion. Findings Included: Record review and observation on 06/08/25 at 09:53 AM, of the 100/200 hall nurse cart , with LVN K revealed missing signatures for Off duty and On duty nurses for 06/06/2025 (6:00 AM to 2:00 PM shift), 06/06/25 (2:00 PM to 10:00 PM shift), and 06/07/2025 (10:00 PM to 6: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for food and nutrition services. 1. The facility failed to ensure food items were properly stored in the facility kitchen on 06/08/25. 2. The facility failed to ensure [NAME] A performed adequate hand hygiene while preparing lunch meal on 06/09/25. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 6 residents (Resident # 63) reviewed for resident rights. The facility failed to ensure Resident # 63 was assisted with eating in a dignified manner on 06/08/25, CNA H stood while feeding the resident. This failure could place residents at risk for decreased quality of life, quality of care, and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure a discharge MDS was electronically completed and transmitted to the CMS System within 14 days after completion for one (Resident #32) of one resident reviewed for discharge assessments. The facility failed to complete and transmit Resident #32's discharge MDS assessment within 14 days of completion. This failure could place the residents at risk of having incomplete records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan for each resident that included measurable objective and timeframes to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #58) of 6 residents reviewed for comprehensive care plans. The facility failed to implement the care plan for Resident #58 by not applying the splint daily to his right arm and hand contraction. This failure could place residents at risk for not having individualized care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for two (Resident #12 and Resident #64) of three residents reviewed for incontinence care. The facility failed to ensure: 1. Resident #64's foley catheter was secured prior to transferring Resident #64 from the toilet to his wheelchair on 06/09/25. 2. The facility failed to ensure CNA G provided appropriate perineal care for Resident #12 when she failed to separate the labia when cleaning the resident on 06/09/25. These failures placed residents at risk for the development and/or worsening of urinary tract infections and dislodgement of the foley catheter.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care, consistent with professional standards of practice for 1 (Resident #63) of 6 residents reviewed for tracheostomy care. LVN I failed to maintain sterile technique during tracheostomy (a surgical opening in the neck providing a direct airway through the trachea) care, and change gloves with hands hygiene going from dirty to clean task. These failures could place residents at risk for respiratory infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not 5% or greater. The facility had a medication error rate of 8 %, based on 2 errors of 25 opportunities, which involved one of five residents (Residents #74) and one of four staff (MA L) reviewed for medication errors, in that: The facility failed to ensure: MA L instructed Resident #74 to chew Aspirin low dose chewable and to place the sublingual (a pharmacological route where medication were placed under the tongue to dissolve and be absorbed directly into the bloodstream) buprenorphine under her tongue when administering medications. These failures could place residents at risk for not receiving therapeutic effects of their medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (100/200 hall nurses cart) of 3 medication nurse cart reviewed for pharmacy services in that: The facility failed to ensure: 1. LVN K responsible for the 100/200 hall nurses cart , removed medications in unsecure containers from the Nurses Cart. 2. The 100/200 hall nurses cart did not have 1 insulin pen for Resident #19 with no open date. Observation of the pen reflected it was used. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from Misappropriation of property for 1 (Resident # 1) of 8 residents reviewed for misappropriation of property. The facility failed to protect Resident #1 from misappropriation of property from CNA A. CNA A used Resident #1's Debit card for unauthorized transactions. The noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 08/24/2024 and ended on 09/03/2024. The facility had corrected the noncompliance before the Incident investigation began on 02/04/2025. This failure could place residents at risk of Exploitation/Misappropriation of Property and loss of lifelong earnings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their written policies and procedures regarding allegations of abuse/neglect for 1(Resident#1) of 8 residents reviewed for abuse/neglect. The facility failed to report a suspicion of misappropriation of property within 24 hours to the state agency as required by their policy. This failure could place all residents at risk of misappropriation of property.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure in response to allegations of abuse, neglect, exploitation, or mistreatment have evidence that all alleged violations were thoroughly investigated and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and the alleged violation is verified appropriate corrective action was taken for 1 of 8 residents (Residents #1) reviewed for Misappropriation of property. The facility failed to investigate and submit the results of their investigation within 5 days as per their policy, after Resident #1 reported his debit card was missing on 08/24/2024. This failure could place residents at risk of Misappropriation of property.

Inspectors wroteBased on interview and record review, the facility failed to immediately consult with the resident 's physician when there was a significant change in the resident 's physical status and a need to alter treatment significantly for two (Residents #17 and #55 ) of ten residents reviewed for notification of changes. 1. ADON C failed to notify the physician and responsible party of Resident #17's change of condition of significant weight loss on 04/28/24. Resident #17's physician was not informed of significant weight loss until 05/06/24. The responsible party for Resident #17 was not notified until 05/07/24. 2. ADON C failed to notify the physician and responsible party of Resident #55's change of condition of significant weight loss on 05/04/24. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary services to maintain good personal hygiene to a resident who is unable to carry out activities of daily living for three of six residents (Resident #536, Resident #4, and Resident #32) reviewed for quality of life. 1. The facility failed to provide Resident #536, who required extensive assistance, with timely incontinence care on 05/7/24 from 6:00 a.m. to 2:20 p.m. 2. The facility failed to provide Resident #4, who required extensive assistance, with timely incontinence care on 05/07/24 from 6:00 a.m. to 2:50 p.m. and failed to consistently shampoo resident's hair. 3. The facility failed to ensure Resident #32 had his fingernails cleaned and trimmed. These failures could place residents at risk of skin breakdown, urinary tract infections, and loss of dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise when the facility failed to implement significant weight loss interventions for two (Residents #17 and #55) of seven residents reviewed for significant weight loss, in that: 1. The facility failed to communicate and follow-up on Resident #17's significant weight loss of 44.8 pounds (20%) from 04/05/24 to 04/28/24 to the facility. Resident #17 was weighed on 05/03/24 revealing Resident #17 had lost 46 pounds (21%) for 1 month period from 04/05/24 to 05/03/24. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure enteral feeding physician orders were followed for two (Residents #17 and #55) of six residents reviewed for enteral tube feeding, in that: 1. The facility failed to verify adequate nutrition was provided via enteral tube feeding or PEG tube (surgical placement of feeding tube in the stomach to provide nutrition, hydration and/or medicines) for Resident #17. 2. The facility failed to notify Consultant Dietitian of Residents #17 and #55's significant weight loss to ensure nutritional interventions were in place. 3. The facility failed to administer enteral feedings for Resident #17 as ordered by the physician. 4. The facility failed to administer enteral feedings to Resident #55 as ordered by the physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care, consistent with professional standards of practice for two of two (Resident #20 and Resident # 76) residents reviewed for tracheostomy care. 1. The facility failed to ensure the RT performed hand hygiene during tracheostomy (a surgical opening in the neck providing a direct airway through the trachea) care. 2. The RT failed to maintain sterile technique during the suctioning of Resident #20's trach. 3. The facility failed to ensure LVN L performed hand hygiene during tracheostomy care for Resident #76 and changed her gloves and performed hand hygiene before applying a clean trach drainage sponge around Resident #76's trach stoma. These failures could place residents at risk for respiratory infections.

Inspectors wroteBased on observations, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food and nutrition services. 1. The facility failed to ensure Dietary Aide ZB wore effective hair restraints to cover his hair and facial hair on 05/07/24 while cleaning dishes and using the dish machine. 2. The facility failed to ensure 1 of 3 freezers were free of ice accumulation on the bottom of freezer. These failures could place residents at risk for food-borne illness and food contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of sixteen residents (Resident #536, Resident #38, and Resident #32) observed for infection control. 1. The facility failed to ensure that CNA K and CNA G performed hand hygiene while providing incontinence care to Resident #536 on 05/07/24 2. CNA G failed to prevent cross contamination with the residents foley catheter bag. 3. The facility failed to ensure that CNA H changed her gloves and performed hand hygiene while providing incontinence care to Resident #38 on 05/08/24. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for one of one laundry room reviewed for environment. 1. The facility failed to properly dispose and maintain the lint accumulation in the facility dryers in a timely manner. 2. The facility failed to properly maintain sanitary handwashing area in the laundry room hand washing station and for the laundry employee restroom. This failure could put residents at risk for an unsafe and unsanitary environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 (Resident #486) of 6 residents reviewed for resident rights. The facility failed to ensure Resident #486's call light was placed within their reach. This failure could place residents at risk of injuries and unmet needs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents for 1 (Resident #486) of 6 residents reviewed for quality of care. The facility failed to ensure Resident #486 wore a helmet, as ordered by physician, to prevent possible injury when ambulating. This failure could result in residents to experience accident, injuries, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of two residents (Resident #38) reviewed for catheter care. The facility failed to ensure CNA H provided catheter care and appropriate perineal care for Resident #38 when she failed to clean the resident's penis, scrotum, and buttocks on 05/08/24. This failure could place residents at risk for the development and/or worsening of urinary tract infections and skin breakdown.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 3 (Resident #38, Resident #55, Resident #67) of 8 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #38 had his fingernails trimmed and cleaned. 2- Resident #55 had his fingernails trimmed and cleaned. 3- Resident #67 had her fingernails cleaned This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide food that was palatable, attractive, and at an appetizing temperature, and prepared by methods which conserved the nutritive value, flavor, and appearance for one of one meals (03/22/23 lunch) reviewed for dietary services. The facility failed to ensure residents on regular diet received beans that were not burnt and overcooked for lunch on 03/22/23. This deficient practice placed residents at risk for poor food intake and nutrition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of medical records for 1 (Resident #23) of 4 residents reviewed for privacy and confidentiality. The facility failed to ensure LVN D logged out of his computer and protected Resident#23's Medication Administration Record. This failure could place residents at risk for low self-esteem, loss of dignity and decreased quality of life due to medication administration record being accessible to others.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents for 1 (nurses medication cart) of 3 medication carts reviewed for medication storage. The facility failed to ensure: The medication supplies were secured or attended by authorized staff when the nurses' cart in hall 400 was left unlocked and unattended in the hallway 400. This failure could place residents at risk to access and ingest of medications leading to a risk for harm and could lead to missing medication.