Brentwood Place Three

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Feb 6, 2026

  Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision for 1 of 5 residents (Resident #1) reviewed for elopement. The facility failed to ensure Resident #1 was adequately supervised when Resident #1 left the faciity on [DATE] and climbed through the fence and walked blocks away from the facility. Resident #1 contacted 911 and was transported to a nearby hospital. Resident #1 was located at a nearby hospital after the previous SW had called around to the closest hospital trying to find Resident #1. Staff did not know what time he left but were aware of his exit-seeking behavior and previous elopement attempt from the facility.An IJ was identified on 02/05/2026. […]

• No harm, potential for more than minimal, widespreadF804Jul 22, 2021

  Based on observation, interview and record review, the facility failed to provided food and drink that was palatable, attractive and at a safe and appetizing temperature for one of one kitchen. A. During confidential interviews, eight residents voiced concerned of cold food, flavor and/or texture and one resident that was not a confidential interview. B. Eight of the 12 foods sampled on the meal tray had temperature issues. C. Three of the 12 foods sampled on the meal tray had flavor issues. D. Two of the 12 foods sampled on the meal tray had texture issues. These failures affected three of three forms produced in the facility (regular, mechanical chopped and pureed) and could result in a decline in resident consumption of food and cause resident unwanted weight loss. […]

• No harm, potential for more than minimal, widespreadF812Jul 22, 2021

  Based on observation, interview and record review, the facility failed to ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety; in that: Cook D and DM C cleaned the thermometer probe with the same paper towel in between taking temperatures of the different food items on the steam table. These failures could result in the cross contamination and spread of foodborne illness in the facility. Findings include: Observation on 07/21/19 at 12:20 PM, Cook D took the temperature of food on the steam table before serving residents and she used the same paper towel in wiping the thermometer probe in between food temperatures. An interview with Cook D was not appropriate at the time due to lateness of the serving of the meal. […]

• No harm, potential for more than minimal, patternF565Mar 19, 2026

  Based on observation, interview, and record review, the facility failed to provide the Resident Council group a private space for monthly resident council meetings for the facility's only resident council, for 18 of 18 confidential residents reviewed for resident rights. The facility failed to ensure resident council meetings were held in a private meeting space during their monthly scheduled March Resident Council meeting, when staff continued to enter the dining room while the resident council meeting was being held. […]

• No harm, potential for more than minimal, patternF812Mar 19, 2026

  Based on observations, interviews, 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 reviewed for food safety.1. The facility failed to ensure the stand-by freezer food items were dated and labeled.2. The facility failed to ensure the stand-by refrigerator food items were dated, labeled, and sealed.3. The facility failed to ensure that serving utensils were used when handling food items.These failures could place residents at risk for foodborne illness and foodborne intoxication.Findings included:During an observation on 03/17/2026 at 8:48 a.m. […]