Brentwood Extended Care & Rehab

In the surveyor’s words

From the most serious findings on record at Brentwood Extended Care & Rehab, in the surveyor’s own words.

• Immediate jeopardy, patternF689May 21, 2024

  On 05/20/24, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents were protected from falls with major injury. Res #1 had a non-injury fall on 04/11/24. Record review and interview confirmed hourly checks were not documented as completed. Res #1 had a fall on 04/14/24 resulting in a broken neck. On 05/17/24, Res #1's call light was observed unplugged, and wrapped up on top of the dresser. Res #2 had a fall with minor injury on 04/20/24. No interventions were developed following the fall according to facility policy. Res #2 had a fall on 04/23/24 resulting in a broken back. The intervention for this fall was to move the resident closer to the nurse's station. […]

• No harm, potential for more than minimal, widespreadF851Jul 31, 2025

  Based on record review and interview, the facility failed to ensure the required PBJ staffing data was submitted to CMS for the second quarter of FY 2025. The administrator identified 55 residents resided in the facility.Findings: A PBJ Staffing Data Report, dated 01/01/25 through 03/31/25 (second quarter of FY 2025), showed the facility had not provided staffing data to CMS for the PBJ staffing data report for the quarter. On 07/31/25 at 11:00 a.m., the office manager stated the employee that handled submitting the PBJ staffing data to CMS no longer worked at the facility and that at the time they did not have anyone that was able to send the data. They stated they now have multiple employees can submit the staffing data.

• No harm, potential for more than minimal, widespreadF880Jul 19, 2021

  Based on observation, interview, and record review, it was determined the facility failed to implement their infection control program to prevent potential spreading of COVID-19 infection for all staff and residents. The facility failed to maintain Centers for Disease Control (CDC) recommended infection control practices related to screening of staff and visitors for COVID-19 signs and symptoms before entry into the facility. This had the potential to affect 70 of 70 residents who resided at the facility. Findings: The facility's policy and procedure on COVID-19 visitation, dated 03/22/21, documented, . All visitors will complete questionnaire related to symptoms, travel, and have their temperature taken . All visitors will be screened prior to entering the door . […]

• No harm, potential for more than minimal, patternF584Mar 25, 2024

  Based on observation, record review, and interview, the facility failed to ensure: a. the floors were maintained in a safe manner; b. the window blinds, wall, and wheelchair was in good repair for one (#30) of eight sampled resident rooms observed; and c. the washing machines were in proper working order. The administrator identified 49 residents who resided in the facility. Findings: The facility's Maintenance Service policy, revised 12/2009, read in part, .The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe operable manner at all times .Functions of maintenance personnel include .Maintaining the building in good repair and free from hazards . […]

• No harm, potential for more than minimal, patternF638Mar 25, 2024

  Based on record review and interview, the facility failed to ensure quarterly resident assessments were completed within 14 days of the assessment reference date for two (#24 and #29) of four sampled residents whose resident assessments were reviewed. The administrator identified 49 residents who resided in the facility. Findings: 1. Res #24's quarterly resident assessment, dated 10/12/23, was not completed and signed until 11/09/23. 2. Res #29's quarterly resident assessment, dated 10/22/23, was not completed and signed until 11/28/23. On 03/21/24 at 1:12 p.m. the administrator reported the resident assessments should have been completed and signed within 14 days and could not explain why that was not done.