Brentwood Health Care Center

In the surveyor’s words

From the most serious findings on record at Brentwood Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF880Nov 23, 2022

  Based on observation, interview, and record review, the facility failed to properly prevent and control the spread of COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and spread from person to person) in accordance with the facility's infection prevention and control program (IPCP) policies and follow infection control practices by failing to: 1. Ensure that all residents with COVID-19 infection confirmed by testing, or those residents who are recovering from COVID are placed in a dedicated COVID-19 positive unit (red zone, area in the facility for residents confirmed with COVID-19 infection). 2. Ensure there was a designated breakroom for staff working in the red zone. 3. […]

• No harm, potential for more than minimal, widespreadF686Jan 23, 2026

  Based on observation, interview, and record review, the facility failed to prevent the deterioration of pressure injuries (localized damage to skin and underlying soft tissue, usually over bony prominences [heels, hips, tailbone], caused by prolonged pressure, friction, or [NAME]) and provided care and services consistent with professional standards of practice for one out of three sampled residents (Resident 1) who had multiple pressure ulcers/injuries by failing to:1. Set the low air loss (LAL - a medical bed system with air-filled cells that let out tiny amounts of air through microscopic holes to keep the user's skin cool, dry, and moisture-free. It acts like a floating surface that reduces pressure on the body, actively prevents bedsores, and helps heal existing skin ulcers. […]

• No harm, potential for more than minimal, widespreadF812Dec 4, 2025

  Based on observation, interview, and record review, the facility failed to ensure dietary staff did not store foods in the kitchen beyond their expiration date and meat was not sitting in a dark reddish liquid. This deficient practice of storing food in the kitchen beyond their expiration date and meat sitting in a dark reddish liquid may cause all residents possible serious complications from foodborne illnesses (refer to illnesses such as nausea, vomiting, and diarrhea, caused by the ingestion of contaminated food or beverages). […]

• No harm, potential for more than minimal, widespreadF812Oct 18, 2024

  Based on observation, interview, and record review, the facility failed to ensure safe food storage practices in the kitchen for by failing to ensure expired canned food, corned beef hash 6-pound (lbs., unit of measurement) 12 ounce (oz, is a unit of measurement) was not stored in the same location as non-expired food to be served to residents in the food storage area along with all other canned foods not expired. The corned beef hash was expired on ,d+[DATE]. This deficient practice had the potential to result in harmful bacteria growth and the consumption of spoiled food that could lead to foodborne illness (caused by contamination of food and occur at any stage of the food production, delivery, and consumption chain) in 57 of 57 residents who received food from the kitchen. […]

• No harm, potential for more than minimal, patternF550Oct 18, 2024

  Based on observation, interview, and record review, the facility failed to ensure staff provided dignified dining experience while assisting two of 15 sampled residents (Residents 4 and 58) during meals; by ensuring Residents 4 and 58 were fed at eye level to maintain face-to-face contact with the residents. This deficient practice had the potential to result in feelings of decreased self-esteem and self-worth for Resident 4 and Resident 58). b. During a review of Resident 58's admission record indicated the facility admitted the resident on 9/26/2024 with diagnoses that included dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing) and muscle weakness (a lack of strength in the muscles). […]