Brentwood Place Two

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Feb 29, 2024

  Based 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 06/30/23 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. […]

• Immediate jeopardy, isolatedF757Feb 29, 2024

  Based 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 06/30/23 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. […]

• Immediate jeopardy, isolatedF656Jul 13, 2023

  Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one of four residents (Resident #1) reviewed for care plans. The facility failed to implement a care plan which included monitoring and interventions to prevent Resident #1 (who was identified with severe cognitive impairment and being at moderate risk for elopement) from eloping from the facility, unsupervised on 06/24/23 and his whereabouts remained unknown. An Immediate Jeopardy (IJ) situation was identified on 07/19/23. […]

• Immediate jeopardy, isolatedF689Jul 13, 2023

  Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of four residents (Resident #1) reviewed for supervision. The facility failed to implement procedures, monitoring and interventions to prevent Resident #1 (who was identified with severe cognitive impairment and being at moderate risk for elopement) from eloping from the facility unsupervised on 06/24/23 and his whereabouts remained unknown. An Immediate Jeopardy (IJ) situation was identified on 06/28/23 at 1:02 p.m. […]

• No harm, potential for more than minimal, widespreadF925Jun 16, 2022

  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 for one (1) of one (1) facility reviewed for pest control program. The facility was observed to have live common house flies in areas of the facility including the kitchen, hallways, and the dining room. This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life. Findings Included: Observation 06/16/22 at 11:58 a.m., revealed live house flies in the kitchen. Two live house flies were observed landing on the bowls used for lunch. One live house fly landed on wrapped fresh fruit. […]