ElderGrade

Inspection citations at Brentwood Extended Care & Rehab

47 citations on record, 1 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2025 5 0
2024 26 1
2023 16 0
D July 31, 2025 Tag F0677 Corrected Sep 2025

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

D July 31, 2025 Tag F0610 Complaint investigation Corrected Sep 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

No actual harm, potential for more than minimal harm

D July 31, 2025 Tag F0609 Complaint investigation Corrected Sep 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, potential for more than minimal harm

D July 31, 2025 Tag F0607 Complaint investigation Corrected Sep 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

No actual harm, potential for more than minimal harm

F July 31, 2025 Tag F0851 Complaint investigation Corrected Sep 2025

Administration Deficiencies

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

No actual harm, potential for more than minimal harm

D December 27, 2024 Tag F0684 Complaint investigation Corrected Mar 2025

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

D December 27, 2024 Tag F0609 Complaint investigation Corrected Mar 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, potential for more than minimal harm

D December 27, 2024 Tag F0600 Complaint investigation Corrected Nov 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

No actual harm, potential for more than minimal harm

D December 27, 2024 Tag F0580 Complaint investigation Corrected Mar 2025

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

No actual harm, potential for more than minimal harm

K May 21, 2024 Tag F0689 Complaint investigation Corrected Jun 2024

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Immediate jeopardy to resident health or safety

D March 25, 2024 Tag F0919 Corrected Jun 2024

Environmental Deficiencies

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

No actual harm, potential for more than minimal harm

D March 25, 2024 Tag F0908 Corrected Jun 2024

Environmental Deficiencies

Keep all essential equipment working safely.

No actual harm, potential for more than minimal harm

D March 25, 2024 Tag F0757 Corrected Jun 2024

Pharmacy Service Deficiencies

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

No actual harm, potential for more than minimal harm

D March 25, 2024 Tag F0732 Corrected Jun 2024

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

No actual harm, potential for more than minimal harm

D March 25, 2024 Tag F0695 Corrected Jun 2024

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

D March 25, 2024 Tag F0690 Corrected Jun 2024

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

D March 25, 2024 Tag F0688 Corrected Jun 2024

Quality of Life and Care Deficiencies

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.

No actual harm, potential for more than minimal harm

D March 25, 2024 Tag F0655 Corrected Jun 2024

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

D March 25, 2024 Tag F0644 Corrected Jun 2024

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

D March 25, 2024 Tag F0641 Corrected Jun 2024

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

No actual harm, potential for more than minimal harm

D March 25, 2024 Tag F0637 Corrected Jun 2024

Resident Assessment and Care Planning Deficiencies

Assess the resident when there is a significant change in condition

No actual harm, potential for more than minimal harm

D March 25, 2024 Tag F0582 Corrected Jun 2024

Resident Rights Deficiencies

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

No actual harm, potential for more than minimal harm

E March 25, 2024 Tag F0881 Corrected Jun 2024

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

No actual harm, potential for more than minimal harm

E March 25, 2024 Tag F0880 Corrected Jun 2024

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

E March 25, 2024 Tag F0760 Corrected Jun 2024

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

No actual harm, potential for more than minimal harm

E March 25, 2024 Tag F0697 Corrected Jun 2024

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

E March 25, 2024 Tag F0684 Corrected Jun 2024

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

E March 25, 2024 Tag F0677 Corrected Jun 2024

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

E March 25, 2024 Tag F0645 Corrected Jun 2024

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

No actual harm, potential for more than minimal harm

E March 25, 2024 Tag F0638 Corrected Jun 2024

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

E March 25, 2024 Tag F0584 Corrected Jun 2024

Resident Rights Deficiencies

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.

No actual harm, potential for more than minimal harm

E November 21, 2023 Tag F0921 Complaint investigation Corrected Jan 2024

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

No actual harm, potential for more than minimal harm

D August 1, 2023 Tag F0689 Complaint investigation Corrected Sep 2023

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D August 1, 2023 Tag F0584 Complaint investigation Corrected Sep 2023

Resident Rights Deficiencies

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.

No actual harm, potential for more than minimal harm

D February 22, 2023 Tag F0888 Corrected May 2023

Infection Control Deficiencies

Ensure staff are vaccinated for COVID-19

No actual harm, potential for more than minimal harm

D February 22, 2023 Tag F0645 Corrected May 2023

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

No actual harm, potential for more than minimal harm

D February 22, 2023 Tag F0637 Corrected May 2023

Resident Assessment and Care Planning Deficiencies

Assess the resident when there is a significant change in condition

No actual harm, potential for more than minimal harm

D February 22, 2023 Tag F0578 Corrected May 2023

Resident Rights Deficiencies

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.

No actual harm, potential for more than minimal harm

E February 22, 2023 Tag F0851 Corrected May 2023

Administration Deficiencies

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

No actual harm, potential for more than minimal harm

E February 22, 2023 Tag F0848 Corrected May 2023

Administration Deficiencies

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

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.