F
33/100BRENTWOOD EXTENDED CARE & REHAB Inspection Report, Violations & Safety Grade (MUSKOGEE, Oklahoma)
841 NORTH 38TH STREET, MUSKOGEE, Oklahoma 74401
Phone: 9186838070
CMS Overall:1/5
Overview & Bed Count
Certified Beds
90
Avg Residents/Day
53.1
Ownership
For profit - Individual
Provider Type
Medicare and Medicaid
County
Muskogee
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall1/5
Health2/5
Staffing1/5
Quality1/5
Nurse Staffing Check
| Metric | This Facility | Oklahoma Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.21 | 0.34 | -0.12 |
| Total Nurse Hours per Resident per Day | 2.91 | 3.82 | -0.91 |
| CMS Staffing Rating | 1/5 | 2.7/5 | - |
| Nursing Staff Turnover | N/A | 55.4% | - |
Health Citation History
45 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-07-31 | Administration Deficiencies | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | F – Moderate Harm Potential |
| 2025-07-31 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | D – Moderate Harm Potential |
| 2025-07-31 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2025-07-31 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2025-07-31 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2024-12-27 | 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. | D – Moderate Harm Potential |
| 2024-12-27 | 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. | D – Moderate Harm Potential |
| 2024-12-27 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2024-12-27 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2024-05-21 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | K – Immediate Jeopardy |
| 2024-03-25 | 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. | E – Moderate Harm Potential |
| 2024-03-25 | Resident Assessment and Care Planning Deficiencies | Assure that each resident’s assessment is updated at least once every 3 months. | E – Moderate Harm Potential |
| 2024-03-25 | Resident Assessment and Care Planning Deficiencies | PASARR screening for Mental disorders or Intellectual Disabilities | E – Moderate Harm Potential |
| 2024-03-25 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | E – Moderate Harm Potential |
| 2024-03-25 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | E – Moderate Harm Potential |
| 2024-03-25 | Quality of Life and Care Deficiencies | Provide safe, appropriate pain management for a resident who requires such services. | E – Moderate Harm Potential |
| 2024-03-25 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | E – Moderate Harm Potential |
| 2024-03-25 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2024-03-25 | Infection Control Deficiencies | Implement a program that monitors antibiotic use. | E – Moderate Harm Potential |
| 2024-03-25 | Resident Rights Deficiencies | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | D – Moderate Harm Potential |
| 2024-03-25 | Resident Assessment and Care Planning Deficiencies | Assess the resident when there is a significant change in condition | D – Moderate Harm Potential |
| 2024-03-25 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | D – Moderate Harm Potential |
| 2024-03-25 | Resident Assessment and Care Planning Deficiencies | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | D – Moderate Harm Potential |
| 2024-03-25 | 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 | D – Moderate Harm Potential |
| 2024-03-25 | 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. | D – Moderate Harm Potential |
| 2024-03-25 | 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. | D – Moderate Harm Potential |
| 2024-03-25 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2024-03-25 | Nursing and Physician Services Deficiencies | Post nurse staffing information every day. | D – Moderate Harm Potential |
| 2024-03-25 | Pharmacy Service Deficiencies | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D – Moderate Harm Potential |
| 2024-03-25 | Environmental Deficiencies | Keep all essential equipment working safely. | D – Moderate Harm Potential |
| 2024-03-25 | Environmental Deficiencies | Make sure that a working call system is available in each resident's bathroom and bathing area. | D – Moderate Harm Potential |
| 2023-11-21 | Environmental Deficiencies | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | E – Moderate Harm Potential |
| 2023-02-22 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | E – Moderate Harm Potential |
| 2023-02-22 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E – Moderate Harm Potential |
| 2023-02-22 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | E – Moderate Harm Potential |
| 2023-02-22 | Pharmacy Service Deficiencies | 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. | E – Moderate Harm Potential |
| 2023-02-22 | Administration Deficiencies | Provide timely, quality laboratory services/tests to meet the needs of residents. | E – Moderate Harm Potential |
| 2023-02-22 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2023-02-22 | Administration Deficiencies | Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | E – Moderate Harm Potential |
| 2023-02-22 | Administration Deficiencies | Provide a neutral and fair arbitration process and agree to arbitrator and venue. | E – Moderate Harm Potential |
| 2023-02-22 | Administration Deficiencies | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | E – Moderate Harm Potential |
| 2023-02-22 | 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. | D – Moderate Harm Potential |
| 2023-02-22 | Resident Assessment and Care Planning Deficiencies | Assess the resident when there is a significant change in condition | D – Moderate Harm Potential |
| 2023-02-22 | Resident Assessment and Care Planning Deficiencies | PASARR screening for Mental disorders or Intellectual Disabilities | D – Moderate Harm Potential |
| 2023-02-22 | Infection Control Deficiencies | Ensure staff are vaccinated for COVID-19 | D – Moderate Harm Potential |
Fire Safety Citation History
14 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2024-03-25 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2024-03-25 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | F – Moderate Harm Potential |
| 2024-03-25 | Egress Deficiencies | Install emergency lighting that can last at least 1 1/2 hours. | C – Minimal Harm Potential |
| 2024-03-25 | Egress Deficiencies | Have properly located and lighted "Exit" signs. | C – Minimal Harm Potential |
| 2024-03-25 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | C – Minimal Harm Potential |
| 2023-02-22 | Egress Deficiencies | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | E – Moderate Harm Potential |
| 2023-02-22 | Egress Deficiencies | Conform to length requirements for dead end corridors. | E – Moderate Harm Potential |
| 2023-02-22 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | E – Moderate Harm Potential |
| 2023-02-22 | Smoke Deficiencies | Provide properly protected cooking facilities. | E – Moderate Harm Potential |
| 2023-02-22 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2021-07-19 | Smoke Deficiencies | Properly select, install, inspect, or maintain portable fire extinguishes. | F – Moderate Harm Potential |
| 2021-07-19 | Egress Deficiencies | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | E – Moderate Harm Potential |
| 2021-07-19 | Smoke Deficiencies | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | E – Moderate Harm Potential |
| 2021-07-19 | Miscellaneous Deficiencies | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | E – Moderate Harm Potential |
Total Penalties & Fines
$97,625
Total Fine Amount (CMS)
9
Number of Fines
9
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2024-03-25 | Fine | $32,709 | - |
| 2024-02-12 | Fine | $4,938 | - |
| 2024-01-22 | Fine | $14,814 | - |
| 2024-01-08 | Fine | $4,938 | - |
| 2024-01-02 | Fine | $4,587 | - |
| 2023-12-11 | Fine | $13,762 | - |
| 2023-11-20 | Fine | $4,587 | - |
| 2023-11-13 | Fine | $4,587 | - |
| 2023-10-23 | Fine | $12,703 | - |
Need Help Finding Safe Care?
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3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the MUSKOGEE area at no cost.
Find Safe, Vetted Facilities Near MUSKOGEE
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.