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Inspection visit

Health inspection

BRENTWOOD EXTENDED CARE & REHABCMS #37517413 citations on this visit
13 citations recorded

Citations

13 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0645GeneralS&S Dpotential for harm

    F645 - Preadmission Screening for individuals with a mental disorder and individuals

    PASARR screening for Mental disorders or Intellectual Disabilities

  • 0656GeneralS&S Epotential for harm

    F656 - Comprehensive Care Plans

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0848GeneralS&S Epotential for harm

    F848 - Arbitrator/Venue Selection and Retention of Agreements

    Provide a neutral and fair arbitration process and agree to arbitrator and venue.

  • 0851GeneralS&S Epotential for harm

    F851 - Mandatory submission of staffing information based on payroll data in a

    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

  • 0888GeneralS&S Dpotential for harm

    Ensure staff are vaccinated for COVID-19

  • 0637GeneralS&S Dpotential for harm

    F637 - Within 14 days after the facility determines, or should have determined,

    Assess the resident when there is a significant change in condition

  • 0641GeneralS&S Epotential for harm

    F641 - Accuracy of Assessments

    Ensure each resident receives an accurate assessment.

  • 0770GeneralS&S Epotential for harm

    F770 - Laboratory Services

    Provide timely, quality laboratory services/tests to meet the needs of residents.

  • 0812GeneralS&S Epotential for harm

    F812 - Food safety requirements

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0847GeneralS&S Epotential for harm

    F847 - Entering Into Binding Arbitration Agreements

    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

  • 0578GeneralS&S Dpotential for harm

    F578 - The right to request, refuse, and/or discontinue treatment, to participate in or

    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.

  • 0657GeneralS&S Epotential for harm

    F657 - Comprehensive Care Plans

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0758GeneralS&S Epotential for harm

    F758 - Medication Errors

    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.

FAQ · About this visit

Common questions about this visit

What happened during the February 22, 2023 survey of BRENTWOOD EXTENDED CARE & REHAB?

This was a inspection survey of BRENTWOOD EXTENDED CARE & REHAB on February 22, 2023. The surveyor cited 13 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at BRENTWOOD EXTENDED CARE & REHAB on February 22, 2023?

Yes, 13 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "PASARR screening for Mental disorders or Intellectual Disabilities"

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.