Brentwood Place Two

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for one (Resident #1) of five residents reviewed for pharmacy services. The facility failed to enter a physicians' order for Nitroglycerin 0.4mg sublingual tablet that was administered to Resident #1 on 06/19/2026. This failure could place residents at risk of not receiving medications as ordered by the physician and a delay in treatment and worsening of their condition.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the resident had a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 3 of 10 residents restrooms (Resident Restroom [ROOM NUMBER], Resident Restroom [ROOM NUMBER], and Resident Restroom [ROOM NUMBER]) reviewed for hot water, 1 of 10 (Resident Restroom [ROOM NUMBER]) for restroom leaks and 1 of 8 residents (Resident #58) reviewed for bed linens. The facility failed to ensure residents had hot water in Resident Restroom [ROOM NUMBER], Resident Restroom [ROOM NUMBER], and Resident Restroom [ROOM NUMBER] on 3/3/26 and 3/4/26. The facility failed to ensure Resident Restroom [ROOM NUMBER] was free from leaks on 3/3/26 and 3/4/26. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration for 3 of 6 residents (Resident #29, Resident #15 and Resident #89) reviewed for hydration. The facility failed to ensure Residents#29 received a drink during lunch service on 3/3/26. The facility failed to ensure Resident #15 received a drink during lunch services on 3/3/26 and 3/4/26. The facility failed to provide Resident #89 drinking water on 3/3/26. These could place residents at risk of discomfort, dehydration, and/or a diminished quality of life. 1. Record review of Resident #29's face sheet, dated 3/5/26, revealed a [AGE] year-old male with an admission of 1/6/25. Resident #29 had the following active diagnoses: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food safety for the facility's only kitchen. The facility failed to ensure the holding temperature was below 40 degrees F (Fahrenheit) for pureed potato salad served for lunch on 3/4/26. This failure could place residents at risk for food-borne illness, and food contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health for 1 of 5 residents (Resident #66) reviewed for foot care. The facility failed to provide adequate foot care for Resident #66. This failure could place residents at risk for infection, impaired mobility, and poor foot health as well as a decline in their quality of life. Record review of Resident #66's face sheet, dated 3/5/26, reflected a [AGE] year-old male, admitted [DATE]. Resident #66 had the following active diagnoses: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for one of two (Residents #92) residents reviewed for feeding tubes. The facility failed to ensure LVN G administered medications through Resident #92's G-Tube by gravity, and instead she pushed the water flushes and medication with the plunger and syringe on 03/03/26. This failure could place residents at risk of abdominal discomfort, nausea and tube rupture.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care were provided with such care, consistent with professional standards of practice and the comprehensive person-centered care plan, for one of two (Resident #71) reviewed for quality of care. The facility failed to ensure the supplemental oxygen was provided at the physician ordered rate for Resident #71. This failure could place residents who received oxygen therapy at risk of oxygen toxicity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured and stored in accordance with current accepted professional principles for 1 of 3 medication carts (Nurse cart for Hall 200) observed for medication storage. The facility failed to ensure LVN G kept Resident #92's medications secured during medication administration on 03/03/26. This failure could place residents at risk of gaining access to unlocked medications that were not prescribed to them.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the therapeutic diets as prescribed by the attending physician for 1 (Resident #13) of 3 residents observed for therapeutic diets. The facility failed to provide Resident #13 with his regular diet minced and moist (MM5) texture as designated on his physician order on 3/4/2026. This failures could place residents at risk for poor intake, weight loss, unmet nutritional needs, and choking.

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 1 (Resident #1) of 6 residents reviewed for ADLs. The facility failed to ensure Staff provided consistent showers/baths for Resident #1. 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 observation, interview and record review the facility failed to ensure that a resident with urinary incontinence, based on the resident's comprehensive assessment, received the appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #1) of 6 residents reviewed for incontinent care. The facility failed to ensure Resident #1 was assisted with incontinence care and toileting in a timely manner on 06/04/2025. This failure could place residents at risk of skin breakdown, infection and a diminished quality of life by not receiving care and services to meet their toileting needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one (Resident #1) of six resident observed for infection control. Facility failed to ensure CNA A performed hand hygiene and changed gloves while providing incontinence care to Resident # 1. Facility failed to ensure CNA A and LVN B performed hand hygiene before touching clean gloves. This failure could place the residents at risk for infection.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to accommodate the needs and preferences of four of 10 residents (Resident #3, Resident #20, Resident #96, and Resident #19) reviewed for accommodation of needs. The facility failed to place Resident #3's call light within reach on 12/11/2024. The facility failed to place Resident #20's call light within reach on 12/11/2024. The facility failed to place Resident #96's call light within reach from 12/10/2024 until 12/11/2024. The facility failed to place Resident #19's call light within reach on 12/11/2024. This failure could place residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for two (Hall 100 and Hall 600) of six halls observed for physical environment. The facility failed to ensure rooms and bathrooms toilets, and sinks were clean, safe, and in good repair in several rooms on Hall 100 and Hall 600. These failures could place residents at risk for diminished quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all assistive devices were maintained and free of hazards for six (Residents #22, #34, #48, #60, #67, and #89) of 6 residents reviewed for essential equipment. The facility failed to properly maintain wheelchairs for Residents #22, #34, #48, #67, and #89. The facility failed to properly maintain the overbed table for Resident #60. These failures could place residents at risk for equipment that is in unsafe operating condition, that could cause injury.

Inspectors wroteBased on observations, interviews, 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 seven of eight ( RN A, CNA D, CNA G, CNA H, CNA I, CNA J, and MA K) staff members and forty-four of 106 residents (Residents #79, #46, #2, #84, #8, #34, #4, #1, #31, #55, #6, #13, #65, #5, #87, #107, #4, #28, #7, #76, #10, #21, #106, #93, #16, #103, #104, #74, #27, #64, #29, #33, #72, #40, #54, #47, #81, #43, #63, #24, #58, #97, and #99) reviewed for infection control procedures. MA K failed to sanitize the blood pressure cuff before and after usage on Resident #63. RN A failed to disinfect her treatment scissors prior to starting a treatment on Resident #99's foot. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, including acute charting guidelines and high blood pressure necessary to care for resident's needs as identified through resident assessments and nursing documentation, for 1 (Resident #63) of 2 residents reviewed for quality of care. 1. MA K failed to communicate, and use the acute charting guidelines in the MAR, for charting of the increased blood pressure, and report to the charge nurse. By not reporting or domenting LVN B was unaware Resident #63 required a follow-up assessment, due to an increased blood pressure. These failures placed residents at risk for complications to include unnoticed change in condition and for residents not to receive needed nursing assessments.

Inspectors wroteBased on interviews, observations, and record reviews, the facility failed to obtain timely laboratory services to meet the needs of its residents for one (Resident #59) of five residents reviewed for laboratory services. The facility failed to collect labs for Resident #59 on 12/06/2024 as ordered by the physician. This failure could place residents at risk for a delay in ensuring treatment needs are identified and addressed.

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 in the facility's kitchen reviewed for food safety. 1. The facility failed to ensure dented cans were placed in a separate storage area. These failures could place residents at risk for food-borne illness and cross contamination.

Inspectors wroteBased on interview and record review, the facility failed ensure residents were free of any significant medication errors for one (Residents #1) of five residents reviewed for medications. 1. The facility failed to ensure LVN A held the Losartan Potassium 100 MG oral tablet when Resident #1's diastolic pressure and pulse was less than 60 on 10/05/24. 2. The facility failed to ensure RN B held the Losartan Potassium 100 MG oral tablet and Hydralazine HCl 50 MG oral tablet when Resident #1' diastolic pressure and pulse was less than 60 on 10/12/24. 3. The facility failed to ensure LVN C held the Hydralazine HCl 50 MG oral tablet when Resident #1's diastolic pressure and pulse was less than 60 on 10/05/24 and 10/06/24. 4. The facility failed to ensure RN D held the Hydralazine HCl 50 MG oral tablet when Resident #1's diastolic pressure and/or pulse was less than 60 on 10/04/24 and 10/08/24. [...]

Inspectors wroteBased on interview, and record review, the facility failed to protect a resident's right to be free from neglect for 1 (Resident #1) of two residents reviewed for neglect. The facility failed to protect Resident #1 from neglect when they failed to conduct adequate therapeutic drug monitoring of Resident #1's lab levels who was receiving lithium. This led to Resident #1 being admitted to acute care hospital on [DATE] and was diagnosed with acute toxic encephalopathy secondary to lithium toxicity. Lab records revealed Resident #1's lithium level was 5.3 mmol/L (critical level) when he arrived at the hospital. The noncompliance was identified as PNC. The IJ began on 06/01/23 and ended on 10/02/23. The facility had corrected the noncompliance before the survey began on 02/27/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen did not have an excessive dose, for an excessive duration, with inadequate monitoring for 1 of 2 residents (Resident #1) reviewed for unnecessary medications. The facility failed to conduct adequate therapeutic drug monitoring of Resident #1's lab levels who was receiving lithium. This led to Resident #1 being admitted to acute care hospital on [DATE] and was diagnosed with acute toxic encephalopathy secondary to lithium toxicity. Lab records revealed Resident #1's lithium level was 5.3 mmol/L (critical level) when he arrived at the hospital. The noncompliance was identified as PNC. The IJ began on 06/01/23 and ended on 10/02/23. The facility had corrected the noncompliance before the survey began on 02/27/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable for 3 (Resident #3, #4, #5) of 9 residents reviewed for food palatability. The facility failed to serve food that was palatable and nutritive. This failure could affect residents by placing them at risk of weight loss, altered nutritional status and diminished quality of life. Findings Included: Record Review of Resident #4 was a [AGE] year-old admitted to the facility 2 ½ years ago. Interview on 2/27/24 at 12:23 p.m. Resident #4, said the quality of the food is horrible and tasted bad. Record Review of Resident #5 was a [AGE] year-old admitted to the facility on [DATE]. Interview on 2/28/24 at 11:13 a.m. with Resident #5, laughed when asked how the food was at the facility. Resident said it was a joke and is not good at all. Interview on 2/28/24 at 4:40 p.m. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure all alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the allegations were made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for one (Resident #1) of five residents reviewed for abuse and neglect. The facility failed to report allegation of neglect involving Resident #1 to the appropriate State Agency immediately on 04/21/23. This failure could place residents at risk of abuse and neglect. Findings Include: Record Review of Resident #1's Comprehensive MDS, dated [DATE], reflected he was a [AGE] year-old male admitted to the facility on [DATE]. [...]

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 2(Nurses Cart halls 100/200 and Med Aide cart halls 400/500) of 3 carts reviewed for pharmacy services. The facility failed to ensure: 1- LVN A, responsible for Nurses cart halls 100/200, counted controlled drugs every shift change and removed medications in unsecure containers from the Nurses Cart. 2- MA B responsible for Med Aide cart halls 400/500, counted controlled drugs every shift change. Thes failures could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings Included: [...]

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. 1. The facility failed to discard food stored in the refrigerator that should no longer be consumed. 2. The facility failed to discard food stored in the dry storage that should no longer be consumed. 3. The facility failed to ensure staff are only using clean utensils when accessing bulk foods. 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 ensure a resident who is fed by enteral means receives the appropriate treatment to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and stomach ulcers for 1 of 1 resident fed by gastrostomy tube (g-tube) (Resident #57), in that: The facility failed to ensure LVN C administered medication by gravity, he pushed them in via g-tube. This failure could result in residents aspirating (inhaling into airway) gastric contents and/or stomach ulcers in residents with a g-tube.

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 Nurse Medication cart) of 3 medication carts reviewed for pharmacy services in that: The facility failed to ensure the 100/200 Hall Nurse Medication cart did not have an expired Assure Dose Control Solution. This failure could affect residents resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for two of eleven (Resident #1 and Resident #2) residents reviewed for environment. The facility failed to ensure that Resident #1's room had repaired windowsill and wall. The facility failed to ensure that Resident#2's room had repaired walls. This failure could place residents at risk for living in an unsafe, unsanitary, and uncomfortable environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with or without an indwelling catheter, receives the appropriate care and services to prevent urinary tract infection to the extent possible for one (Resident#3) of six residents reviewed for incontinent care. The facility failed to ensure Resident #3 was assisted with incontinence care and toileting in a timely manner. This failure could place residents at risk of a diminished quality of life by not receiving care and services to meet their toileting needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident with urinary incontinence, based on the resident's comprehensive assessment , received the appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #3) of 6 residents reviewed for incontinent care. The facility failed to ensure Resident #3 was assisted with incontinence care and toileting in a timely manner. This failure could place residents at risk of a diminished quality of life by not receiving care and services to meet their toileting needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one (Resident #3) of six resident observed for infection control. Facility failed to ensure CNA B performed hand hygiene and changed gloves while providing incontinence care to Resident # 3. This failure could place the residents at risk for infection.