Brentwood Place One

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one of four (Resident #4) reviewed for range of motion. The facility failed to apply Resident #4's splints to his left and right hand and braces to right and left foot as ordered by the physician. This failure could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts observed for medications labeling and storage. The Hall 400/500 medication cart contained an over-the-counter medication bottle of Aspirin CR 81 mg oral tablet with faded and nonvisible expiration date on 04/07/26. This failure could place residents at risk for not receiving the therapeutic benefit of the medication or adverse reaction to expired medication. During observation/interview on 04/07/26 at 10:42 AM of the medication cart for Hall 400/500 with MA C, revealed top-drawer holding over the counter residents' medications. [...]

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 1 of 5 residents (Resident #8) reviewed for infection control. The facility failed to have Resident#8 ,with dialysis permanent catheter ( a medical device used to access the bloodstream for dialysis) and undated dressing, was on enhanced barrier precaution. This failure could place residents at risk for infection and cross contamination. A record review of Resident #8's Quarterly MDS assessment, dated 03/04/26, reflected Resident #8 was a [AGE] year-old male admitted to the facility on [DATE], and readmitted on [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one of six (Residents #3) reviewed for Reasonable Accommodation of Needs. The facility failed to provide a working communication system, that was easily at reach, that would allow Resident #3 the ability to safely call for staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for daily living.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 residents (Resident #1 and #Resident #2) of 6 residents reviewed for ADLs. The facility failed to ensure: 1. Resident #1 had her fingernails cleaned and trimmed on 07/22/25.2. Resident #2 had her fingernails cleaned and trimmed on 07/22/25. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a de

Inspectors wroteBased on observation, interviews, and record review the facility failed to provide a safe, clean, comfortable environment, including but not limited to receiving treatments and supports for daily living for 3 of 4 residents (Resident #88, Resident #44 and Resident #92) reviewed for quality of life. The facility failed to provide Resident #88 and Resident #44 a comfortable and warm room above 71 degrees for 1/20/25 and 1/21/25. The facility failed to provide Resident #92 a comfortable and warm room with the temperature above 71 degrees on 1/20/25 through 1/21/25. The facility failed to provide residents who attended a confidential interview in the Rehab/Therapy room, a warm and comfortable room between above 71 degrees on 1/21/25. These failures could affect the residents by causing hypothermia or exacerbating existing conditions.

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 and to restore continence to the extent possible for one of one resident (Resident #79) reviewed for catheter and incontinence care. 1. The facility failed to ensure RA F maintained the foley catheter drainage bag below Resident #79's bladder while she and CNA G transferred the resident with a mechanical lift on 01/20/25 2. The facility failed to ensure CNA B did not place the urine catheter bag on the bed while performing incontinence care for Resident #79 and failed to maintain the drainage bag below the bladder while she and ADON E transferred the resident with a mechanical lift on 01/21/25. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 1 (med aid cart hall400/500) of 3 medication carts reviewed for pharmacy services and for 1 (Resident #31) of 5 residents reviewed for pharmacy services in that: The facility failed to ensure: 1- MA responsible for Nurses Cart Hall 500, removed medications in unsecure containers from the Nurses Cart when on 01/20/25 a-controlled medication used for pain had 1 blister seal broken and the pill still inside the broken blister and tapped over. 2- LVN J followed the manufacturer's instructions to prime the Novolog Insulin (Hormone) Pen prior to dialing in required amount of Insulin to be administered to Resident #31 on 01/21/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food prepared that conserved nutritive value, flavor, and appearance for 10 residents on pureed diets of 10 residents on pureed diet , reviewed for nutritive value, in that: Cook A did not follow the recipe for the pureed (is cooked food, usually vegetables, fruits, or legumes, that has been ground, pressed, blended, or sieved to the consistency of a creamy paste or liquid) Spaghetti served for lunch service on 1/21/25. This failure could place residents at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and 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 2 resident (Resident #38 and Resident #82) of 8 residents observed for infection control, and for 1 closet of 1 closet observed for sanitary environment. The facility failed to ensure: 1- CNA H changed her gloves and performed hand hygiene while providing incontinence care to Resident #38 on 01/21/25. 2- Clean linen closets were kept sanitary on 01/21/25. 3- Resident mattress was cleaned from the bowel movement before putting new fitted sheet on the bed for Resident #82 on 01/21/25. These failures could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 residents ( Resident #7 and #Resident #82 ) of 16 residents reviewed for ADLs. The facility failed to ensure: 1. Resident #7 had her fingernails cleaned and trimmed on 01/20/25. 2. Resident #82 had her fingernails cleaned and trimmed on 01/21/25. These failures 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 review, the facility failed to ensure that residents had a comfortable and homelike environment for one (100 - hall) of six halls reviewed for physical environment. The facility failed to ensure the temperatures on the facility's 100 - hall was maintained at a range of 71° to 81° Fahrenheit when the heating unit would not produce hot air. This failure placed residents at risk of living in an uncomfortable environment leading to a decreased quality of life.

Inspectors wroteBased on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen in that: The facility failed to ensure the morning cook checked the temperatures of the breakfast food before serving to residents. This failure could place residents who ate the food from the kitchen at risk for food-borne illness

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident maintained acceptable parameters of nutritional status, unless the resident's clinical condition demonstrated that this was not possi ble, for one (Resident #66) of three residents reviewed for nutrition, in that: Resident #66 had a weight loss -11.8% in 30-day period with weekly weight loss intervention not implemented as outlined in the facility policy. This failure could place residents at increased risk of decline in physical health.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #73) of three resident reviewed for respiratory care. The facility failed to ensure Resident #73's nasal cannula, nebulizer mask, and oxygen tubing were dated. The facility failed to ensure Resident #73's nebulizer mask was properly stored. The facility failed to ensure Resident #73 had an order for continuous O2 administration. These failures could place the resident at risk for respiratory infection and not having their respiratory needs met.