Deficiency Records for The Brentwood Rehabilitation and Healthcare Ctr
Updated as of April 01, 2024
A list of the most recent deficiencies for The Brentwood Rehabilitation and Healthcare Ctr. 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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-02-02 | 2023-03-10 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-02-02 | 2023-03-10 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-02-02 | 2023-03-10 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-02-02 | 2023-03-10 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-02-02 | 2023-03-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-02 | 2023-03-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-02-02 | 2023-03-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-02-02 | 2023-03-10 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2023-02-02 | 2023-03-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-12 | 2023-02-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-12 | 2023-02-01 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-01-12 | 2023-02-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-12 | 2023-02-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-12 | 2023-02-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-12 | 2023-02-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-01-12 | 2023-02-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-12 | 2023-02-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-13 | 2022-07-25 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-07-13 | 2022-07-25 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-03-25 | 2021-04-16 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-03-25 | 2021-04-16 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-03-25 | 2021-04-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-25 | 2021-04-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-03-25 | 2021-04-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-03-25 | 2021-04-16 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-03-25 | 2021-04-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-03-25 | 2021-04-16 | 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 | 2021-03-25 | 2021-04-16 | N |
| Provide or obtain dental services for each resident. | Health | 2021-03-25 | 2021-04-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-25 | 2021-04-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-25 | 2021-04-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-04-15 | 2021-04-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-22 | 2019-11-01 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-08-22 | 2019-09-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-08-22 | 2019-09-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-22 | 2019-09-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-08-22 | 2019-09-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-08-22 | 2019-09-30 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-08-22 | 2019-09-30 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-06-11 | 2019-07-01 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-06-11 | 2019-07-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-06-11 | 2019-07-01 | N |
| Respond appropriately to all alleged violations. | Health | 2019-06-11 | 2019-07-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-11 | 2019-07-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-06-11 | 2019-07-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-06-11 | 2019-07-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-06-11 | 2019-07-01 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-06-11 | 2019-07-01 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-06-11 | 2019-07-01 | N |
| Provide or obtain dental services for each resident. | Health | 2019-06-11 | 2019-07-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-06-11 | 2019-07-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-11 | 2019-07-01 | N |
