Brentwood Place One

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jul 21, 2023

  Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect for one (Resident #1) of twenty residents reviewed for neglect. 1) On 07/15/23, LVN A unlocked and opened an exit door to allow Resident #1 to leave a secured unit without supervision. Resident #1 had not been located was not located as of 07/21/23. 2) LVN A failed to evaluate Resident #1's mental status, pertinent medical conditions, mental health diagnoses, risk of harm to self or tried to prevent the departure when Resident #1 stated wanting to leave the facility. […]

• Immediate jeopardy, isolatedF692Sep 23, 2022

  Based on observation, interview, and record review, the facility failed to provide a therapeutic diet that takes into account the resident's clinical condition, and preferences, when there is a nutritional indication foods of choice ordered for a [AGE] year-old Korean female resident's therapeutic diet needs to ensure the resident maintained acceptable parameters of nutritional status when there was a nutritional problem for 1 of 6 residents (Resident #43) reviewed for unplanned weight loss. 1. The facility failed to implement the dieticians' and Speech Language Pathologist recommendations which resulted in severe weight loss 18.5%for Resident #43. 2. […]

• No harm, potential for more than minimal, widespreadF812Jul 7, 2021

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure food items were dated/labeled/sealed and free from spills in the upright double-door freezer. 2. The facility failed to ensure food items were kept away from airborne contaminants. These failures could place residents at risk for food-borne illness. Findings include: 1. […]

• No harm, potential for more than minimal, widespreadF925Jul 7, 2021

  Based on observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for two of ten resident rooms (Residents # 36 and #80), and one of six halls (Hall 300) , and the dining room reviewed for pests. The facility failed to ensure an effective pest control program when there were flies in two resident rooms, in the dining room, and on Hall 300. This failure could place residents at risk of a decreased lack of quality of life and food borne illnesses. […]

• No harm, potential for more than minimal, patternF584Jan 22, 2025

  Based 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. […]