Deficiency Records for Brentwood Terrace Healthcare and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Brentwood Terrace Healthcare and Rehabilitation. 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? |
|---|---|---|---|---|
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-20 | 2023-11-21 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-08-04 | 2023-08-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-04 | 2023-08-05 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-07 | 2023-03-10 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-02-07 | 2023-02-22 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-01-11 | 2023-02-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-01-11 | 2023-02-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-11 | 2023-02-13 | 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 | 2023-01-11 | 2023-02-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-01-11 | 2023-02-13 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-01-11 | 2023-02-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-11 | 2023-02-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-11 | 2023-02-13 | N |
| Have policies on smoking. | Health | 2023-01-11 | 2023-02-13 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-01-11 | 2023-02-10 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-01-11 | 2023-02-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-11 | 2023-02-02 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-01-11 | 2023-02-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-11 | 2023-02-02 | 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 | 2023-01-11 | 2023-02-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-11 | 2023-01-25 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-11 | 2023-01-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-11 | 2022-04-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-21 | 2021-11-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-21 | 2021-11-18 | N |
| Provide activities to meet all resident's needs. | Health | 2021-10-21 | 2021-11-18 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-10-21 | 2021-11-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-21 | 2021-11-18 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-10-21 | 2021-11-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-21 | 2021-11-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-21 | 2021-11-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-22 | 2021-11-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-22 | 2021-08-31 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-03-11 | 2021-04-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-25 | 2019-10-11 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-09-25 | 2019-10-03 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-09-25 | 2019-10-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-25 | 2019-10-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-09-25 | 2019-10-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-25 | 2019-10-03 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-09-25 | 2019-10-03 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-09-25 | 2019-10-03 | N |
