A list of the most recent deficiencies for Brentwood Health Care Center. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-22 | 2023-02-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-22 | 2023-02-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-22 | 2023-02-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-12-22 | 2023-02-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-22 | 2023-02-01 | 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 | 2022-12-22 | 2023-02-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-22 | 2023-02-01 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-12-22 | 2023-02-01 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-12-22 | 2023-02-01 | 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 | 2022-12-22 | 2023-02-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-12-19 | 2023-02-01 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-04 | 2022-03-22 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-06-07 | 2021-07-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-07 | 2021-07-07 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2019-10-03 | 2019-11-01 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-10-03 | 2019-11-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-03 | 2019-11-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-03 | 2019-11-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-03 | 2019-11-01 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-10-03 | 2019-11-01 | N |
| Post nurse staffing information every day. | Health | 2019-10-03 | 2019-11-01 | 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 | 2019-10-03 | 2019-11-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-10-03 | 2019-11-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-03 | 2019-11-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-03 | 2019-11-01 | N |
| Dispose of garbage and refuse properly. | Health | 2019-10-03 | 2019-11-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-03 | 2019-11-01 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-10-03 | 2019-11-01 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-10-03 | 2019-11-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-10-02 | 2019-11-01 | 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 | 2019-10-02 | 2019-11-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-02 | 2019-11-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-10-02 | 2019-11-01 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-10-02 | 2019-11-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-02 | 2019-11-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-10-02 | 2019-11-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-10-02 | 2019-11-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-02 | 2019-11-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-10-02 | 2019-11-01 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-08-30 | 2018-09-21 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-08-30 | 2018-09-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-30 | 2018-09-21 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2018-08-30 | 2018-09-21 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2018-08-30 | 2018-09-21 | 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 | 2018-08-27 | 2018-09-21 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-08-27 | 2018-09-21 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-08-27 | 2018-09-21 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2018-08-27 | 2018-09-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-08-27 | 2018-09-21 | N |
