Brentwood Place Four

In the surveyor’s words

From the most serious findings on record at Brentwood Place Four, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF677Jun 11, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF755Jun 11, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF812Jun 11, 2025

  Based 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. Findings included: Observation on 6/8/25 at 9:30 AM revealed a scoop in the bulk oatmeal bin in the dry storage area. […]

• No harm, potential for more than minimal, patternF602Feb 5, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF607Feb 5, 2025

  Based 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. Findings included: Record review of Resident #1's face sheet dated 02/05/2025 revealed he was a [AGE] year-old male with an admitted [DATE]. […]