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Inspection visit

Health inspection

BRENTWOOD EXTENDED CARE & REHABCMS #37517421 citations on this visit
21 citations recorded

Citations

21 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.

  • 0655GeneralS&S Dpotential for harm

    F655 - Comprehensive Person-Centered Care Planning

    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

  • 0677GeneralS&S Epotential for harm

    F677 - A resident who is unable to carry out activities of daily living receives

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0684GeneralS&S Epotential for harm

    F684 - Quality of care

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0582GeneralS&S Dpotential for harm

    F582 - The facility must—

    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

  • 0584GeneralS&S Epotential for harm

    F584 - Safe Environment

    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.

  • 0644GeneralS&S Dpotential for harm

    F644 - Coordination

    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

  • 0645GeneralS&S Epotential for harm

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

    PASARR screening for Mental disorders or Intellectual Disabilities

  • 0757GeneralS&S Dpotential for harm

    F757 - Unnecessary Drugs—General

    Ensure each resident’s drug regimen must be free from unnecessary drugs.

  • 0760GeneralS&S Epotential for harm

    F760 - Residents are free of any significant medication errors

    Ensure that residents are free from significant medication errors.

  • 0880GeneralS&S Epotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 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

  • 0638GeneralS&S Epotential for harm

    F638 - Quarterly Review Assessment

    Assure that each resident’s assessment is updated at least once every 3 months.

  • 0641GeneralS&S Dpotential for harm

    F641 - Accuracy of Assessments

    Ensure each resident receives an accurate assessment.

  • 0688GeneralS&S Dpotential for harm

    F688 - Mobility

    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.

  • 0690GeneralS&S Dpotential for harm

    F690 - Incontinence

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  • 0695GeneralS&S Dpotential for harm

    F695 - Respiratory care, including tracheostomy care and tracheal suctioning

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0697GeneralS&S Epotential for harm

    F697 - Pain Management

    Provide safe, appropriate pain management for a resident who requires such services.

  • 0732GeneralS&S Dpotential for harm

    F732 - Nurse Staffing Information

    Post nurse staffing information every day.

  • 0881GeneralS&S Epotential for harm

    F881 - Infection prevention and control program

    Implement a program that monitors antibiotic use.

  • 0908GeneralS&S Dpotential for harm

    F908 - Maintain all mechanical, electrical, and patient care equipment in safe

    Keep all essential equipment working safely.

  • 0919GeneralS&S Dpotential for harm

    F919 - Resident Call System

    Make sure that a working call system is available in each resident's bathroom and bathing area.

FAQ · About this visit

Common questions about this visit

What happened during the March 25, 2024 survey of BRENTWOOD EXTENDED CARE & REHAB?

This was a inspection survey of BRENTWOOD EXTENDED CARE & REHAB on March 25, 2024. The surveyor cited 21 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at BRENTWOOD EXTENDED CARE & REHAB on March 25, 2024?

Yes, 21 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted"

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.