Inspection Reports for Brentwood Health and Rehabilitation
115 BRENTWOOD DRIVE, WAYNESBORO, GA, 30830
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 15, 2025, identified multiple deficiencies related to resident privacy, oxygen therapy care plans, linen cart storage, and food labeling and sanitation. Earlier inspections showed a pattern of similar issues with oxygen therapy, infection control, and food safety, along with recurring Life Safety Code deficiencies involving sprinkler maintenance and fire safety. Complaint investigations during this period were mostly unsubstantiated, and no fines, immediate jeopardy findings, or license actions were listed in the available reports. Prior follow-up surveys confirmed correction of earlier deficiencies, but recent findings suggest ongoing challenges in care plan implementation and environmental safety. The overall trend indicates that while some past issues were addressed, new and recurring deficiencies have emerged in recent inspections.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
7.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
55% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
74 residents
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jun 15, 2025
Visit Reason
A State Licensure survey was conducted at MGHP Brentwood from June 13, 2025, through June 15, 2025, to assess compliance with state health regulations and identify any deficiencies.
Findings
The survey revealed multiple deficiencies including failure to maintain resident privacy during care, improper implementation of oxygen therapy care plans for three residents, improper storage of clean and soiled linen carts increasing infection risk, and inadequate labeling and sanitation of food items and dumpsters posing risks of food-borne illness and pest infestation.
Deficiencies (4)
Failure to ensure resident R6 was treated with full visual privacy during care, risking diminished dignity.
Failure to implement oxygen therapy care plans correctly for residents R31, R122, and R11, including incorrect oxygen flow rates.
Failure to ensure clean and soiled linen carts were stored separately on three of five halls, risking infection spread.
Failure to label food items with open and discard dates and maintain dumpsters in sanitary condition with fitted lids and doors.
Report Facts
Residents sampled: 29
Residents receiving oxygen therapy: 11
Residents with oxygen therapy deficiencies: 3
Halls with linen cart storage issues: 3
Residents at risk from food sanitation issues: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA CC | Certified Nursing Assistant | Named in privacy deficiency for resident R6 |
| LPN EE | Licensed Practical Nurse | Confirmed oxygen flow rate error for resident R11 |
| LPN DD | Licensed Practical Nurse | Confirmed oxygen flow rate error for resident R122 |
| Director of Nursing | Director of Nursing | Interviewed regarding privacy curtains and oxygen therapy care plan expectations |
| MDS Coordinator | Licensed Practical Nurse / Minimum Data Set Coordinator | Confirmed care plans for oxygen therapy for residents R31, R11, and R122 |
| Infection Preventionist | Infection Preventionist Nurse | Confirmed linen cart storage issues and infection control education |
| Dietary Manager | Dietary Manager | Confirmed food labeling and dumpster sanitation deficiencies |
| Dietary Aide JJ | Dietary Aide | Provided observations on food labeling deficiencies |
| Dietary Aide HH | Dietary Aide | Observed dumpster sanitation issues |
| Maintenance Assistant GG | Maintenance Assistant | Observed dumpster sanitation issues |
| Receptionist II | Receptionist | Reported on dumpster repair requests and city response |
| Administrator | Administrator | Interviewed regarding privacy curtains and linen cart storage expectations |
Inspection Report
Routine
Census: 74
Deficiencies: 9
Date: Jun 15, 2025
Visit Reason
A standard survey was conducted from June 13, 2025 through June 15, 2025, including investigation of Complaint Intake Number GA00254017 in conjunction with the standard survey.
Complaint Details
Complaint Intake Number GA00254017 was investigated and substantiated with no deficiencies found related to the complaint.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations with multiple deficiencies including failure to maintain resident dignity and privacy, failure to refer a resident for PASRR Level II screening, failure to implement care plans for oxygen therapy, failure to administer oxygen as ordered, failure to prevent avoidable falls, failure to post daily nursing staffing numbers, failure to properly label and date food items, failure to maintain dumpsters in sanitary condition, and failure to separate clean and soiled linen carts to prevent infection.
Deficiencies (9)
Failed to ensure one resident was treated with dignity and provided full visual privacy during care.
Failed to refer one resident with qualifying diagnosis to PASRR Level II for review.
Failed to implement care plans for oxygen therapy for three residents.
Failed to administer oxygen therapy as ordered by physician for three residents.
Failed to provide care and services to avoid preventable falls for one resident.
Failed to post daily nursing personnel staffing numbers for direct care.
Failed to ensure food items were labeled with open and/or discard dates and discarded on or before discard dates.
Failed to maintain two of three dumpsters in sanitary condition with fitted lids and doors to prevent exposure to insects and rodents.
Failed to ensure clean and soiled linen carts were not stored together, increasing risk of infection transmission.
Report Facts
Residents sampled: 29
Residents receiving oxygen therapy: 11
Residents with care plan implementation failure: 3
Residents with oxygen administration errors: 3
Residents at risk for falls: 1
Staffing posting last updated: May 24, 2025
Residents receiving oral diet: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA CC | Certified Nursing Assistant | Named in dignity/privacy deficiency for resident R6 |
| LPN BB | Licensed Practical Nurse | Observed fall risk deficiency related to resident R6 |
| LPN AA | Licensed Practical Nurse | Responsible nurse for oxygen therapy administration for resident R31 |
| LPN EE | Licensed Practical Nurse | Observed oxygen flow rate error for resident R11 |
| LPN DD | Licensed Practical Nurse | Observed oxygen flow rate error for resident R122 |
| Director of Nursing | Director of Nursing | Provided multiple confirmations and expectations regarding privacy, PASRR, oxygen therapy, fall prevention, and staffing postings |
| Administrator | Administrator | Confirmed expectations for PASRR, fall prevention education, staffing postings, and linen cart storage |
| Dietary Manager | Dietary Manager | Confirmed food labeling deficiencies and dumpster issues |
| Dietary Aide JJ | Dietary Aide | Observed food labeling deficiencies and dumpster conditions |
| Maintenance Assistant GG | Maintenance Assistant | Observed dumpster conditions |
| Receptionist II | Receptionist | Reported dumpster issues and communication with city |
| Infection Preventionist | Infection Preventionist | Confirmed improper storage of clean and soiled linen carts |
Inspection Report
Life Safety
Census: 74
Capacity: 103
Deficiencies: 2
Date: Jun 14, 2025
Visit Reason
The visit was conducted to perform a Life Safety Code Survey and review the Emergency Preparedness Program for Brentwood Health and Rehabilitation.
Findings
The facility was found not in substantial compliance with Life Safety Code requirements, specifically related to sprinkler system maintenance and combustible decorations. Electrical wiring was observed lying on sprinkler piping affecting 50% of the facility, and several resident room curtains were not fire retardant.
Deficiencies (2)
Sprinkler piping was not free from all electrical wiring, affecting 50 percent of the facility and residents.
Curtains in resident rooms were not fire retardant, affecting 50 percent of residents and staff.
Report Facts
Census: 74
Total Capacity: 103
Percentage of facility affected: 50
Percentage of residents and staff affected: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of electrical wiring on sprinkler piping and non-fire retardant curtains during facility tour |
Inspection Report
Abbreviated Survey
Census: 65
Deficiencies: 0
Date: May 30, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00247059.
Complaint Details
Complaint GA00247059 was investigated and found to be unsubstantiated.
Findings
The complaint GA00247059 was unsubstantiated and no deficiencies were cited related to the complaint.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 17, 2023
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor during the follow-up visit.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 11, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Brentwood Health and Rehabilitation following a survey completed on 10/11/2023.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies in the provided page.
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 0
Date: Oct 11, 2023
Visit Reason
An unannounced visit was conducted to investigate complaint GA00238652 in conjunction with a Revisit Survey from 10/10/2023 to 10/11/2023.
Complaint Details
Complaint GA00238652 was investigated and found unsubstantiated with no deficiencies.
Findings
The complaint GA00238652 was found to be unsubstantiated with no deficiencies identified during the visit.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 11, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the 8/24/2023 Standard Survey and to investigate Complaint Intake Number GA00238652.
Complaint Details
Complaint Intake Number GA00238652 was investigated and found to be unsubstantiated with no deficiencies.
Findings
All deficiencies cited in the 8/24/2023 Standard Survey were found to be corrected. The complaint investigation for GA00238652 was unsubstantiated with no deficiencies identified.
Report Facts
Complaint Intake Number: GA00238652
Previous survey date: 8/24/2023
Inspection Report
Annual Inspection
Census: 45
Deficiencies: 2
Date: Aug 24, 2023
Visit Reason
A standard recertification survey was conducted at MGHP-Brentwood Health and Rehabilitation from August 22, 2023 to August 24, 2023 to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to submit Minimum Data Sets (MDS) assessments within required timeframes for five residents and failure to ensure psychotropic medications were not ordered as needed (PRN) for more than 14 days without clinical indication for two residents.
Deficiencies (2)
Failure to ensure that Minimum Data Sets (MDS) assessments were submitted to CMS within 14 days after completion for five of 27 residents reviewed.
Failure to ensure psychotropic medications, including antianxiety and antidepressant medications, were not ordered as needed (PRN) for more than 14 days unless clinically indicated for two of five residents reviewed.
Report Facts
Resident census: 45
Residents reviewed for MDS assessments: 27
Residents with MDS submission deficiencies: 5
Residents reviewed for unnecessary medications: 5
Sample size for medication review: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Registered Pharmacist | Provided information about pharmacy procedures for psychotropic medication orders |
| MDS Coordinator | Interviewed regarding MDS assessment submissions; noted lack of prior experience and described submission process | |
| Clinical Reimbursement Director | Confirmed MDS assessments had not been transmitted and explained submission process | |
| Director of Nursing (DON) | Confirmed MDS assessments transmission and PRN medication order procedures | |
| Administrator | Confirmed ability to run reports to verify MDS submissions |
Inspection Report
Routine
Deficiencies: 1
Date: Aug 24, 2023
Visit Reason
A State Licensure survey was conducted at MGHP-Brentwood from August 22, 2023 through August 24, 2023 to assess compliance with state health regulations.
Findings
The facility failed to ensure that psychotropic medications, including antianxiety and antidepressant medications, were not ordered as needed (PRN) for more than 14 days unless clinically indicated for two of five residents reviewed. Specifically, orders for lorazepam lacked appropriate stop dates or clinical rationale for continuation beyond 14 days.
Deficiencies (1)
Psychotropic medications, including antianxiety and antidepressant medications, were not ordered as needed (PRN) for more than 14 days unless clinically indicated for two residents.
Report Facts
Sample size: 24
Residents with medication issues: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding PRN medication orders and facility procedures for psychotropic medication management | |
| Registered Pharmacist (RPh) AA | Interviewed regarding pharmacy procedures for psychotropic medication orders and Drug Alert forms |
Inspection Report
Life Safety
Census: 45
Capacity: 103
Deficiencies: 16
Date: Aug 22, 2023
Visit Reason
The inspection was conducted as a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and related fire safety standards.
Findings
The facility was found not in substantial compliance with multiple Life Safety Code requirements including emergency preparedness program deficiencies, fire door locking and closing issues, ceiling tile openings, missing door closers, fire alarm system deficiencies, sprinkler system maintenance issues, blocked fire extinguishers, improperly sealed firewalls, electrical hazards, and blocked electrical panels.
Deficiencies (16)
Emergency Preparedness Program lacked documentation for 1135 Waiver and patient physician phone numbers; no documentation of emergency preparedness training.
Failed to remove dead bolt locks from facility doors affecting dining room and staff break room.
No key available for rear fenced yard gate.
Fire doors on C Hall and B Hall failed to close and latch properly.
Ceiling tiles improperly installed with openings allowing smoke transfer throughout the building.
Missing door closers on housekeeping closet, education room, and B1.
Fire alarm breakers missing breaker locks on two power panels.
Escutcheon rings need fixing in dining hall and clean linen closet.
Office supplies stored too close to sprinkler head in storage closet.
Fire extinguisher in kitchen blocked and not free and clear.
Firewall not properly sealed in P Hall.
Improper installation of power strips and multi plugs in Payroll, Admin, and Nurse Directors offices.
Missing globe in maid closet light fixture.
P Hall electrical panel blocked by chairs.
C Hall electrical panel blocked by furniture.
Exposed wires not enclosed in junction box in attic of B Hall.
Report Facts
Certified beds: 103
Census: 45
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 1, 2022
Visit Reason
An abbreviated survey was conducted to investigate complaint GA00224317.
Complaint Details
Complaint GA00224317 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Life Safety
Census: 51
Capacity: 103
Deficiencies: 0
Date: Nov 9, 2021
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness Program requirements and Life Safety Code standards.
Report Facts
Certified beds: 103
Census: 51
Inspection Report
Renewal
Deficiencies: 0
Date: Nov 4, 2021
Visit Reason
The inspection was conducted as a Licensure Survey from November 2, 2021 through November 4, 2021 to assess compliance for facility licensure renewal.
Findings
No deficiencies were identified during the licensure survey conducted from November 2 through November 4, 2021.
Inspection Report
Routine
Census: 51
Deficiencies: 0
Date: Nov 4, 2021
Visit Reason
A standard survey was conducted at Brentwood Health and Rehabilitation from 11/2/21 through 11/4/21 to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Routine
Census: 55
Deficiencies: 0
Date: Feb 11, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with federal regulations related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 64
Deficiencies: 0
Date: Jul 17, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 65
Deficiencies: 0
Date: Jun 18, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 infection control regulations and had implemented recommended practices to prepare for COVID-19.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 4, 2020
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected during the follow-up visit.
Inspection Report
Life Safety
Census: 75
Capacity: 103
Deficiencies: 4
Date: Dec 10, 2019
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements due to failures in emergency lighting, fire sprinkler system maintenance and testing, smoke barrier door maintenance, and electrical system labeling and maintenance.
Deficiencies (4)
Emergency light outside 'D' hall exit door did not work.
No documentation available for annual fire sprinkler certification.
Resident door to room A-11 does not close and latch secure against smoke or fire.
Electrical panels were not labeled to identify breakers, hindering quick location during electrical problems.
Report Facts
Census: 75
Total Capacity: 103
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 27, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00196467, GA00196648, and GA00196705.
Complaint Details
The complaints GA00196467, GA00196648, and GA00196705 were investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaints investigated during the survey were unsubstantiated and no deficiencies were found.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 26, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00195290.
Complaint Details
Complaint GA00195290 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint was unsubstantiated and no deficiencies were found during the survey.
Inspection Report
Re-Inspection
Census: 89
Deficiencies: 0
Date: Aug 22, 2018
Visit Reason
A revisit survey was conducted from August 20 through August 22, 2018 to investigate complaint intake numbers GA00190355 and GA00190934 and to verify correction of deficiencies cited in the extended recertification survey conducted June 16 through June 22, 2018.
Complaint Details
Complaint Intake Number GA00190355 and GA00190934 were investigated and found to be in substantial compliance.
Findings
All deficiencies cited in the prior extended recertification survey were found to be corrected. The complaint investigation found the facility to be in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B.
Inspection Report
Re-Inspection
Census: 89
Deficiencies: 0
Date: Aug 22, 2018
Visit Reason
A revisit survey was conducted to investigate complaint intake numbers GA00190355 and GA00190934 and to verify correction of deficiencies cited in the prior extended recertification survey conducted June 16-22, 2018.
Complaint Details
Complaint Intake Number GA00190355 and GA00190934 were investigated and found to be in substantial compliance.
Findings
All deficiencies cited in the prior extended recertification survey were found to be corrected. The complaint investigation found the facility to be in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B.
Report Facts
Resident census: 89
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 6, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The survey noted that all previously cited survey tags have been corrected.
Inspection Report
Abbreviated Survey
Census: 93
Deficiencies: 6
Date: Jul 6, 2018
Visit Reason
An Extended Recertification survey was conducted at Brentwood Health and Rehabilitation on 6/18/18 through 6/22/18 due to concerns including multiple resident falls with injuries and an ongoing Immediate Jeopardy related to these issues.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations due to failure to consistently determine the root cause of falls, evaluate and revise care plans with appropriate interventions, provide adequate supervision to prevent falls, maintain sufficient staffing especially in the Memory Care Unit, and ensure effective oversight by administration and the governing body. Immediate Jeopardy was identified related to multiple residents sustaining serious injuries from falls. Corrective actions were validated by the State Survey Agency but the facility remains out of compliance as systematic changes continue.
Deficiencies (6)
Failure to provide consistent evidence of interdisciplinary team input into development and revision of interventions for falls and evaluation of effectiveness for four residents.
Failure to provide supervision to prevent accidents and reassess use of assistive devices for four residents with falls and fractures.
Failure to have sufficient nursing staff with appropriate competencies and skills to provide nursing care and supervision to prevent falls for four residents.
Failure of facility administration to ensure effective falls program and adequate staffing to maintain resident safety and well-being.
Failure of governing body to ensure effective falls program including root cause analysis and quality assurance monitoring.
Failure of Quality Assurance and Performance Improvement committee to effectively identify, develop, implement, and monitor corrective action plans for residents with multiple falls.
Report Facts
Resident census: 95
Resident census: 93
Falls: 11
Residents at high risk for falls: 78
Residents reviewed for falls: 4
Residents reviewed: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator | Named in relation to Immediate Jeopardy notification and corrective actions |
| John Smith | Director of Nursing | Named in relation to Immediate Jeopardy notification and corrective actions |
| Regional Vice President | Regional Vice President | Named as governing body representative and involved in oversight and education |
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 3
Date: Jul 6, 2018
Visit Reason
The inspection was conducted due to a complaint investigation related to falls with fractures involving four residents, with concerns about the facility's failure to implement an effective falls prevention program and adequate staffing to prevent accidents.
Complaint Details
The visit was complaint-related due to multiple falls with fractures among residents. Immediate jeopardy was identified as of 12/1/17 and was ongoing at time of exit on 6/22/18. An acceptable Credible Allegation of Compliance was received on 6/29/18, removing the immediate jeopardy on 6/30/18.
Findings
The facility was found to have immediate jeopardy related to ineffective falls prevention, inadequate supervision, failure to determine root causes of falls, and insufficient staffing. Four residents had multiple falls resulting in fractures. The facility implemented corrective actions including reassessment of residents, therapy evaluations, staff education, and systemic changes to staffing and fall prevention protocols. Immediate jeopardy was removed on 6/30/18 but the facility remained out of compliance while implementing systematic changes.
Deficiencies (3)
Failure to administer an effective falls program that consistently determined the root cause of falls and provided adequate supervision to prevent falls for four residents.
Failure to have sufficient staff to provide supervision to prevent accidents for four residents.
Failure to provide supervision to prevent accidents; failure to provide evidence that falls were consistently discussed in Patients At Risk or Skilled Services meetings; failure to reassess use of bed bolsters and motorized wheelchair after accidents.
Report Facts
Resident census: 95
Residents identified as high risk for falls: 78
Sample size: 46
Falls for Resident #96: 11
Fall Risk Assessment Score: 18
Fall Risk Assessment Score: 12
Fall Risk Assessment Score: 17
Fall Risk Assessment Score: 13
Staff educated: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Received education on job description, QAPI, and falls management; involved in daily staffing reviews and corrective actions | |
| Director of Nursing (DON) | Informed of immediate jeopardy, involved in education, staffing reviews, and falls management | |
| Regional Vice President (RVP) | Provided education to Administrator, involved in daily calls and staffing oversight | |
| Regional Nurse Consultant | Reviewed facility assessment and participated in education and corrective action planning | |
| Licensed Practical Nurse (LPN) AAA | Assigned to Memory Care Unit, involved in staffing and supervision | |
| Certified Nursing Assistants (CNAs) YY, OO, TT, ZZ, BBB, CCC | Dedicated to Memory Care Unit, attended in-services on staffing guidelines |
Inspection Report
Abbreviated Survey
Census: 95
Deficiencies: 5
Date: Jun 22, 2018
Visit Reason
An Extended Recertification survey was conducted to determine compliance with Medicare/Medicaid regulations and assess falls management and resident safety.
Findings
The facility was found not in substantial compliance due to failure to consistently evaluate and revise care plans after falls, inadequate supervision to prevent falls, insufficient nursing staff, and ineffective quality assurance processes related to falls management for four residents with multiple falls and fractures.
Deficiencies (5)
Failure to determine root cause of falls and evaluate effectiveness of interventions for four residents with multiple falls and fractures.
Failure to provide adequate supervision and sufficient nursing staff to prevent falls.
Failure to maintain an effective quality assurance program that identifies, develops, implements, and analyzes corrective action plans for residents with multiple falls.
Failure of governing body to ensure effective falls program and quality assurance oversight.
Failure to consistently revise care plans with interdisciplinary input after falls.
Report Facts
Resident census: 95
Falls: 11
Residents high risk for falls: 78
Resident falls: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Nurse Consultant GG | Regional Nurse Consultant | Interviewed regarding facility governance and quality assurance oversight |
| Administrator | Facility Administrator | Interviewed regarding falls management and quality assurance |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding falls management, care plan revisions, staffing, and quality assurance |
| Licensed Practical Nurse EE | Charge Nurse | Interviewed regarding staffing and supervision on night shift |
| Certified Nursing Assistant CC | CNA | Interviewed regarding staffing and resident supervision |
| Medical Director | Medical Director | Interviewed regarding involvement in falls management and quality assurance |
Inspection Report
Life Safety
Census: 96
Capacity: 103
Deficiencies: 6
Date: Jun 20, 2018
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, including failure to maintain exit ramps, emergency lighting, exit signage, fire sprinkler system maintenance, electrical wiring, and oxygen cylinder safety, placing residents and staff at risk in the event of fire or emergency.
Deficiencies (6)
Failed to maintain walks and ramps out of the south end exit of building, with a 3-inch drop off and no ramp.
Failed to maintain emergency lights; emergency lighting missing from the facility's drug room.
Failed to maintain exit signage in kitchen's back exit; exit signage not operational on DC power.
Failed to maintain fire sprinkler system and components, including painted sprinkler head, corroded sprinkler head, and wiring on sprinkler piping in attic.
Failed to maintain electrical systems; open wiring not in junction box above fire doors and in soiled utility room.
Failed to maintain oxygen cylinders; oxygen cylinder found free standing on a night stand between resident beds.
Report Facts
Census: 96
Total Capacity: 103
Deficiencies cited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 28, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Routine
Census: 87
Deficiencies: 0
Date: Jul 13, 2017
Visit Reason
A standard survey was conducted at Brentwood Health and Rehabilitation from July 10, 2017, through July 13, 2017, to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 85
Capacity: 103
Deficiencies: 7
Date: Jul 13, 2017
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failures in maintaining door closures, emergency lighting, vertical and horizontal penetrations, sprinkler system maintenance, fire walls, and electrical safety. These deficiencies could place all 85 residents and staff at risk in the event of a fire.
Deficiencies (7)
Failed to maintain door closures on exit passageway doors, specifically a broken door closure on the 'A' Hall maintenance closet.
Failed to have emergency lighting covering all exits, including the front main exit door.
Failed to maintain vertical penetrations in the kitchen water heater room.
Failed to maintain horizontal openings in a hazardous area, specifically horizontal penetrations in the kitchen storage room wall.
Failed to maintain the fire sprinkler system; sprinkler heads were loaded with dust and lint and electrical wiring was lying on or strapped to sprinkler piping.
Failed to maintain fire walls; multiple hall fire walls had unsealed penetrations and were not sealed with properly rated fire caulking material.
Failed to properly mount multi-power taps and electrical wiring; power taps were on floors under desks in multiple rooms and electrical wall receptacle cover plate was missing in the clean linen room; open and exposed wiring was observed on the vending room floor.
Report Facts
Residents at risk: 85
Certified beds: 103
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during the facility tour |
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 17, 2017
Visit Reason
A follow-up survey was conducted on 5/17/17 to verify correction of deficiencies identified during the complaint survey of 4/1/17.
Findings
All deficiencies identified in the complaint survey of 4/1/17 had been corrected by the time of the follow-up survey on 5/17/17.
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Apr 1, 2017
Visit Reason
An Abbreviated Survey was conducted to investigate complaints GA00173276, GA00169822, GA00164768 and GA00158781. Two complaints were not substantiated, one was substantiated with no deficiency cited, and one was substantiated with deficiencies cited.
Complaint Details
The survey was conducted in response to complaints GA00173276, GA00169822, GA00164768 and GA00158781. Complaints GA00164768 and GA00158781 were not substantiated. GA00173276 was substantiated with no deficiency cited. GA00169822 was substantiated with deficiencies cited.
Findings
The facility failed to develop a comprehensive, individualized care plan with appropriate interventions for the care of a colostomy and colostomy bag for one resident (R#3). The colostomy bag was not monitored or emptied in a timely manner, causing discomfort to the resident. Additionally, the facility failed to post nurse staffing data daily for public review as required.
Deficiencies (3)
Failed to develop a comprehensive care plan with appropriate interventions for colostomy care for one resident.
Failed to provide timely monitoring and emptying of a colostomy bag filled with gas and stool for one resident.
Failed to post nurse staffing data daily for public review.
Report Facts
Date of survey: Apr 1, 2017
Care plan start date: Nov 6, 2015
Resident admission date: Oct 23, 2015
Resident re-admission date: Oct 13, 2016
MDS assessment date: Sep 17, 2016
MDS assessment date: Oct 17, 2016
MDS assessment date: Jan 13, 2017
MAR documentation period: 31
Last nurse staffing data posted: Mar 27, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding colostomy care and nurse staffing data posting |
| Licensed Practical Nurse | LPN RAI Coordinator | Interviewed about care plan software and interventions |
| CNA AA | Certified Nursing Assistant | Provided colostomy care and interviewed about care practices |
| CNA BB | Certified Nursing Assistant | Assisted with colostomy care observed by surveyor |
| RN Supervisor | Registered Nurse Supervisor | Interviewed about nurse staffing data posting responsibilities |
| Administrator | Facility Administrator | Interviewed about nurse staffing data posting |
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