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Deficiency Records for Brentwood Health Care Center
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.
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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-17 | 2024-05-13 | 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 | 2023-11-27 | 2023-12-22 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-13 | 2023-12-13 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-11-13 | 2023-12-13 | N |
| 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 | 2023-11-13 | 2023-12-13 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-11-13 | 2023-12-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-13 | 2023-12-13 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-11-13 | 2023-12-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-13 | 2023-12-13 | 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 | 2023-11-13 | 2023-12-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-13 | 2023-12-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-13 | 2023-12-13 | 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 | 2023-11-13 | 2023-12-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-13 | 2023-12-13 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-11-13 | 2023-12-13 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-11-13 | 2023-12-13 | 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 | 2023-11-13 | 2023-12-13 | 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 | 2023-11-13 | 2023-12-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-13 | 2023-12-13 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-10-25 | 2023-11-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-03 | 2023-09-22 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-09-03 | 2023-09-22 | N |
| 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 | 2023-09-03 | 2023-09-22 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-08-21 | 2023-09-10 | Y |
| 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 | 2023-07-24 | 2023-08-14 | Y |
| 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 | 2023-07-05 | 2023-07-24 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-07-05 | 2023-07-24 | Y |
| Report COVID19 data to residents and families. | Health | 2023-05-04 | 2023-06-04 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-04-27 | 2023-05-07 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-14 | 2023-03-24 | Y |
| 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 | 2023-03-14 | 2023-03-24 | Y |
| 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 | 2023-02-24 | 2023-03-13 | Y |
| 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 | 2023-02-24 | 2023-03-13 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-02-24 | 2023-03-13 | 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 | 2022-11-23 | 2023-03-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-02-08 | 2023-02-16 | 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 | 2023-02-08 | 2023-02-16 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-08 | 2023-02-16 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-11-23 | 2023-02-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-23 | 2023-02-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-23 | 2023-02-16 | N |
| Post nurse staffing information every day. | Health | 2022-11-23 | 2023-02-16 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-11-23 | 2023-02-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-23 | 2023-02-16 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-11-23 | 2023-02-16 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-23 | 2023-01-16 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-11-23 | 2023-01-16 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-11-23 | 2023-01-16 | N |
| 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 | 2022-11-23 | 2023-01-16 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-11-23 | 2023-01-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-23 | 2023-01-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-23 | 2023-01-16 | 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 | 2022-11-23 | 2023-01-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-23 | 2023-01-16 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-11-23 | 2023-01-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-23 | 2023-01-16 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-11-23 | 2023-01-16 | 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 | 2022-11-23 | 2023-01-16 | 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 | 2022-11-23 | 2023-01-16 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-11-23 | 2023-01-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-23 | 2023-01-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-23 | 2023-01-16 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2022-11-23 | 2023-01-16 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-11-23 | 2023-01-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-11-23 | 2023-01-16 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-11-23 | 2023-01-16 | N |
| Report COVID19 data to residents and families. | Health | 2022-11-23 | 2023-01-16 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-11-23 | 2023-01-16 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-11-19 | 2022-12-21 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-11-19 | 2022-12-21 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-11-19 | 2022-12-21 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2022-11-19 | 2022-12-21 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-11-19 | 2022-12-21 | 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 | 2022-11-19 | 2022-12-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-19 | 2022-12-21 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-11-19 | 2022-12-21 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2022-11-19 | 2022-12-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-19 | 2022-12-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-11-19 | 2022-12-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-11-19 | 2022-12-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-01 | 2022-08-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-21 | 2022-08-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-08 | 2022-07-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-10 | 2022-05-13 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-10 | 2022-05-13 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-24 | 2022-04-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-24 | 2022-04-06 | 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 | 2020-01-09 | 2020-01-31 | N |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2020-01-09 | 2020-01-31 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-01-09 | 2020-01-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-09 | 2020-01-31 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-01-09 | 2020-01-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-09 | 2020-01-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-09 | 2020-01-09 | N |
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