A list of the most recent deficiencies for Brentwood Place Three. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-11-16 | 2023-11-17 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-11-16 | 2023-11-17 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-11-16 | 2023-11-17 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-11-16 | 2023-11-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-16 | 2023-11-17 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-15 | 2023-11-17 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2023-11-15 | 2023-11-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-15 | 2023-11-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-09 | 2023-06-12 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-26 | 2023-05-05 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-04-26 | 2023-05-05 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-04-26 | 2023-05-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-26 | 2023-05-05 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-09-27 | 2022-11-11 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-27 | 2022-09-28 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-09-27 | 2022-09-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-27 | 2022-09-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-27 | 2022-09-28 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-09-27 | 2022-09-28 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-09-27 | 2022-09-28 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-27 | 2022-09-28 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-26 | 2022-09-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-28 | 2022-06-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-02 | 2022-02-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-22 | 2021-08-13 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-07-22 | 2021-08-13 | N |
| Provide activities to meet all resident's needs. | Health | 2021-07-22 | 2021-08-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-07-22 | 2021-08-13 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-07-22 | 2021-08-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-22 | 2021-08-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-07-21 | 2021-08-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-07-21 | 2021-08-13 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-07-21 | 2021-08-13 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2021-07-21 | 2021-08-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-17 | 2021-07-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-17 | 2021-07-09 | Y |
