A list of the most recent deficiencies for Brentwood Extended Care and Rehab. 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 | 2023-08-01 | 2023-09-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-01 | 2023-09-11 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-02-22 | 2023-05-05 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-02-22 | 2023-05-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-02-22 | 2023-05-05 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-02-22 | 2023-05-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-22 | 2023-05-05 | 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 | 2023-02-22 | 2023-05-05 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-02-22 | 2023-05-05 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-02-22 | 2023-05-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-22 | 2023-05-05 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-02-22 | 2023-05-05 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2023-02-22 | 2023-05-05 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-02-22 | 2023-05-05 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-02-22 | 2023-05-05 | 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 | 2023-04-12 | 2023-05-05 | N |
| Conform to length requirements for dead end corridors. | Fire Safety | 2023-04-12 | 2023-05-05 | 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 | 2023-04-12 | 2023-05-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-12 | 2023-05-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-12 | 2023-05-05 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-09 | 2022-09-12 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-08-09 | 2022-09-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-09 | 2022-09-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-09 | 2022-09-12 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-08-09 | 2022-09-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-09 | 2022-09-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-09 | 2022-09-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-09 | 2022-03-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-08 | 2022-02-04 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-12-08 | 2022-02-04 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-08 | 2022-02-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-08 | 2022-02-04 | Y |
| Report COVID19 data to residents and families. | Health | 2021-12-08 | 2022-02-04 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-12-08 | 2022-02-04 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-12-08 | 2022-02-04 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-11-10 | 2022-01-28 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-11-10 | 2021-12-23 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-11-10 | 2021-12-23 | Y |
| 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 | 2021-07-19 | 2021-08-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-07-19 | 2021-08-30 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-07-19 | 2021-08-30 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-07-19 | 2021-08-30 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-07-19 | 2021-08-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-19 | 2021-08-30 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-07-19 | 2021-08-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-19 | 2021-08-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-19 | 2021-08-30 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-07-19 | 2021-08-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-19 | 2021-08-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-19 | 2021-08-30 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-07-19 | 2021-08-30 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-07-19 | 2021-08-30 | 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 | 2021-07-19 | 2021-08-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-19 | 2021-08-30 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-07-19 | 2021-08-30 | 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 | 2021-07-20 | 2021-08-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-07-20 | 2021-08-30 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-07-20 | 2021-08-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-07-20 | 2021-08-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-14 | 2019-07-10 | 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 | 2019-05-14 | 2019-07-10 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-05-14 | 2019-07-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-14 | 2019-07-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-14 | 2019-07-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-05-14 | 2019-07-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-14 | 2019-07-10 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-05-14 | 2019-07-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-05-14 | 2019-07-10 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-05-07 | 2019-07-10 | 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 | 2019-05-07 | 2019-07-10 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-05-07 | 2019-07-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-07 | 2019-07-10 | N |
